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COPVRIGHT DEPOSIT. 



DISEASES OF NUTRITION AND INFANT FEEDING 



THE MACMILLAN COMPANY 

HEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



DISEASES OF NUTRITION 
AND INFANT FEEDING 



BY 

JOHN LOVETT MORSE, A.M., M.D. 

Professor of Pediatrics, Harvard Medical School; Visiting Physician at the 

Children's Hospital ; Consulting Physician at the Infants' 

Hospital and the Floating Hospital, Boston 

AND 

FRITZ B. TALBOT, A.B., M.D. 

Instructor in Pediatrics, Harvard Medical School ; Chief of Children's Medi- 
cal Department, Massachusetts General Hospital; Physician to Chil- 
dren, Charitable Eye and Ear Infirmary; Consulting Physician at 
the Lying-in Hospital and at the Floating Hospital, Boston; 
Collaborator to the Nutrition Laboratory of the Carnegie 
Institution of Washington 



2fom fork 

THE MACMILLAN COMPANY 

1915 

All rights reserved 



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Copyright, 1915, 
By THE MACMILLAN COMPANY. 

Set up and electrotyped. Published, September, 19x5. 



i& 



Norinooti tyres* : 
Berwick & Smith Co., Norwood, Mass., U.S.A. 

©GI.A411407 

SEP -9 1915 
It*! . 



PREFACE 

This book was written to meet what seemed to the authors to be 
two distinct needs in American pediatric literature; a detailed de- 
scription of the scientific basis of rational infant feeding and a 
description of the method of infant feeding taught in the Harvard 
Medical School. In it the authors have endeavored to meet these 
needs. It is intended to satisfy the demands, on the one hand, of 
those students who wish to become acquainted in the original with 
the data on which the scientific basis of infant feeding rests and, on 
the other, of the general practitioner who wishes to learn the clini- 
cal and practical sides of infant feeding. It is hoped that it will 
not only point the way to further investigations but also be of 
service to the clinician in his daily work. 

John Lovett Morse 
Boston, Fritz B. Talbot 

September, 1915. 



TABLE OF CONTENTS 



SECTION I 

PHYSIOLOGY AND METABOLISM 

CHAPTER PAGE 

I. Physiology of Digestion . 1 

II. The Digestion and Metabolism of Fat 18 

III. The Digestion and Metabolism of Carbohydrates. . . 29 

IV. The Digestion and Metabolism of Protein 38 

V. The Metabolism of the Mineral Salts 51 

VI. The Energy Metabolism of Infants 56 

VII. The Bacteriology of the Gastrointestinal Canal. . . 68 

VIII. The Stools in Infancy 77 



SECTION II 

BREAST FEEDING 

IX. Breast Feeding: General Considerations 89 

X. Human Milk: Chemistry and Biology 93 

XL Breast Feeding: Clinical Considerations and Technique 122 

XII. Wet-Nurses 141 

section in 
ARTIFICIAL FEEDING 

XIII. Cow's Milk: Chemistry and Biology 145 

XIV. Cow's Milk: Bacteriology and Chemical Tests. . . . 162 
XV. Sterilization, Boiling and Pasteurization of Milk . . 166 

XVI. Certified Milk 176 

XVII. General Principles of Artificial Feeding 179 

XVIII. The Prescribing of Modified Milk 212 

XIX. The Feeding of Premature Infants 237 

vii 



viii TABLE OF CONTENTS 

SECTION IV 

DISEASES OF THE GASTROINTESTINAL CANAL 

CHAPTER PAGE 

XX. Spasm of the Pylorus 243 

XXI. Hypertrophic Stenosis op the Pylorus 247 

XXII. Nervous Disturbances op the Digestive Tract .... 255 

XXIII. Disturbances of Digestion 257 

XXIV. Indigestion with Fermentation 279 

XXV. Infectious Diarrhea 289 

XXVI. Constipation 307 



SECTION V 

DISEASES OF NUTRITION 

XXVII. Rickets 315 

XXVIII. Infantile Scurvy 327 

Index 337 



DISEASES OF NUTRITION AND INFANT FEEDING 



SECTION I 
PHYSIOLOGY AND METABOLISM 



CHAPTER I 
PHYSIOLOGY OF DIGESTION 

MOUTH 

Food is drawn into the mouth of the infant by the negative 
pressure which results from the act of sucking. This negative 
pressure is between five and fifteen cubic centimetres of mercury or 
between ten and one hundred and forty cubic centimetres of 
water. 1 

Almost all the work on the reaction of the oral cavity has been 
done by older writers and, although their results have not been 
uniform, it seems to be established that the reaction of the mouth 
of the new-born infant is neutral or weakly alkaline before the first 
food is taken. The acid reaction of the mouths of older babies is 
probably due to the breaking down of food remains. Oshima 2 has 
recently demonstrated lactic acid, by Uffelmann's test, in the 
mouths of infants, most often between the ages of three and six 
months. He attributes the presence of this acid to the action of a 
leptothrix. Immediately after birth a baby's mouth is free from 
bacteria, but it very quickly becomes infected. 

The weight of the salivary glands at different ages, as given by 
Berger, 3 is as follows : 

TABLE 1 



Age 


Average 

body 

weight 


Parotid 


Av. wt. 
both sub- 
maxillaries 


Av. wt. 
both sub- 
linguals 


Av. wt. 


Max. wt. 


Min. wt. 


New born 
3 months 
6 months 
2 years 


3580 gm. 
3600 gm. 
,4745 gm. 
9100 gm. 


1.80 
3.18 
4.50 
8.60 


2.4 
4.8 
5.8 
9.6 


0.9 
1.4 
3.1 

8.2 


0.84 
1.53 
2.12 

4.89 


0.42 
0.84 
1.05 
2.00 



1 Gundobin: Die Besonderheiten des Kindesalters, Berlin, 1912, 248. 

2 Oshima: Arch. f. Kinderh., 1907, xlv, 21. 

3 Quoted by Gundobin: Die Besonderheiten des Kindesalters, Berlin, 1912, 
258. 

1 



2 DISEASES OF NUTRITION 

These glands are heavier in healthy and well developed than in 
sickly and poorly developed infants, but considerable individual 
variations are often found. The glands begin to differentiate from 
the epithelium of the mouth in the second month of fetal life and 
can be dissected at the tenth week of fetal life. 

Saliva is secreted during the first week of life and probably dur- 
ing the first day (Joerg, Bidder and Schmidt). It has the power 
of converting starch into sugar as soon as it is secreted. 1, 2> 3 » 4 
Ptyalin is present in both the parotid and submaxillary glands, 3 
Ibrahim was able to demonstrate diastatic ferments in both the 
parotid and submaxillary glands of two fetuses. One of them 
weighed but 150 gm.; the other was in the sixth month of fetal 
life. He thought that there was about the same amount in each 
gland at birth. The diastase in the saliva is only able to digest 
starches as far as maltose and not into grape sugar. 5, 6> 7 Shaw 8 
gave babies a test meal of barley water and washed out their stom- 
achs from fifteen to sixty minutes later. He found that it was 
possible for the diastatic action of saliva to continue in the stomach 
as long as two hours after feeding. It is difficult to say what role 
the saliva of infants plays in the physiology of digestion. Probably 
it plays a very small part. In general, it has been shown, 9, 10, Ui 12, 13 
that the dryer the food, the greater the secretion of saliva. This 
rule, however, does not hold good with milk, 14 the food of babies, 
because considerably more saliva is secreted for a food containing 
milk than for that containing meat. It is admitted, 15 16 however, 
that saliva may cause coagulation of milk and thus help stomach 
digestion. The amount of water, albumen, and mucus in saliva 
varies considerably. 

1 Schlossmann: Jahr. f. Kinderh., 1898, xlvii, 116. 

2 Montague: Diss., 1899, Leiden; Montague: Centralbl. f. Inn. Med., 1900, 
xxi, 705. 

3 Schilling: Jahrb. f. Kinderh., 1903, Neue Folge, lviii, 518. 

4 Moll: Monatsschr. f. Kinderh., 1905-06, iv, 307. 

6 Musculus and Gruber: Zeitschr. f. Phys. Chem., 1878, ii, 177. 

6 Musculus and Mering: Zeitschr. f. Phys. Chem., 1878, ii, 403. 

7 Hamburger: Pfluger Arch., 1895, lx, 543. 

8 Shaw: Albany Med. Annals, Jan., 1904, xxv, 148. 

9 Glinsky: Sitzung d. Gesellsch. russ. Arzte zu. St. Petersburg, 1895. 

10 Wulfson: Diss. St. Petersburg, 1898. 

11 Snarsky: Diss. St. Petersburg, 1901. 

12 Malloizel: Jour. d. Physiol, et Pathol., gener., 1902, 547. 

13 Heymann: Diss. St. Petersburg, 1904. 

14 Sellheim: Diss. St. Petersburg, 1904. 

15 Billard and Dieulate: Comptes rend, de la soc. de biol. a Paris, 1902. 

16 Borissow: Russk. Wrat. 1903, Die letzen 8 Arbeiten, quoted in Noth- 
nagel's Handbuch. 



AND INFANT FEEDING 3 

Finizio l induced infants to suck bits of cotton and then deter- 
mined the amylolytic power of the saliva. This was greatest about 
midday and was different in babies of the same age. When the 
babies were less than six months old, it did not vary after nursing 
or when starch was added to the food, but when they were over 
six months old, there was an increase in the amylolytic power im- 
mediately after a meal containing starchy foods. This increase 
was still noticeable an hour later. Beginning at about six months 
there seemed to be a gradual development of the specificity of 
function of the salivary glands. He tested the saliva of several 
babies monthly during the first year and found that the amylolytic 
power increased progressively from birth to the age of twelve 
months. At eight to ten months it was twice that at birth, and 
at one year a trifle less than that of children two to three years old. 
Allaria 2 found that, after the first weeks of life, the mouth reacted 
acid to litmus paper phenolphthalein, and that the reaction was 
rarely neutral or alkaline. 

STOMACH 

The stomach of the fetus lies completely in the left hypo- 
chondrium, with the exception of the pylorus, which is in the 
median line and is completely covered by the liver. These rela- 
tions change after birth so that at fifteen months the liver no 
longer overlaps the stomach. The position of the stomach of the 
fetus is nearly vertical. In the newly-born child, it lies some- 
what obliquely in the abdomen, and at the end of infancy, it has 
almost reached the transverse position. 

The growth of the fundus compared with that of the stomach as 
a whole is relatively rapid during infancy. The length of the 
fundus of the fetus is 1 js, of the infant 1 / 4 , and of the adult 1 / 3 of 
the total length of the stomach. 3 

The stomach, as would be expected, grows rapidly in size during 
the first year. The greater curvature becomes longer, increasing 
16 to 24 centimeters in length. Pisek and Lewald 4 conclude from 
their investigations with the Roentgen ray that there is no charac- 
teristic normal type of stomach in the infant. It is horizontal 
rather than vertical when compared with the adult type, and fol- 
lows certain rather definite forms. They distinguished (a) the 
ovoid or Scotch bag-pipe type of Flesh and Peteri (b), the tobacco 

1 Finizio: Rev. Hyg. et Med. Infant, viii, No. 3, 224. 

2 Allaria: Monatsschr. f. Kinderh., x, No. 4, 179. 

3 Gundobin: loc. cit., 264. 

4 Pisek and Lewald: Am. Jour. Dis. Children, 1913, vi, 232. 



4 



DISEASES OF NUTRITION 



pouch (retort shape of Alwens and Husler), and (c) the pear- 
shaped stomach with base above and to the left. The shape of 
the stomach does not depend on the amount or character of the 
food ingested, but rather upon the quantity of gas which it con- 
tains or acquires. Major 1 showed that the shape of the Roentgen 
ray picture of the stomach varied with the position of the infant 
and that the movements of the diaphragm could cause changes 
in its appearance. Alwens and Husler (quoted by Pisek 2 ) report, 
furthermore, that they have observed a change in the form from 
the tobacco pouch to the bag-pipe variety after the intestines 
have been emptied. 

Gastric Capacity. — Recent investigations show that the ana- 
tomic gastric capacity, obtained by measuring the capacity of the 
stomach by water poured in post mortem at a pressure of 15 cm. 
(the figures given in most text-books are based on such observa- 
tions), is considerably smaller than the physiologic capacity. The 
physiologic capacity of infants' stomachs is at such variance with 
the anatomic measurements that it is safe to say that a baby can 
digest more than the anatomic size of the stomach would seem to 
warrant. 3 

The following figures were taken from Pfaundler, 4 and repre- 
sent the gastric capacity post mortem with a pressure of 15 c. c. 
water. 

TABLE 2 



Age of infant 


Months 


1 


2 


3 


4 


6 


8 


10 


12 


Systolic stomach 


150 


175 


210 
200 


235 
230 


290 
295 


360 
365 


430 

445 


490 


Diastolic stomach 


515 



The gastric capacity, determined post mortem by Holt, 5 is as 
shown by table 3 on page 5. 

Tables 2 and 3 represent the gastric capacity of infants with 
closed pyloric valves which allowed no food to escape into the 
intestine. Mosenthal investigated the gastric capacity of in- 
fants during life (physiological capacity) and post mortem (ana- 
tomic capacity), and found that the former was always larger 

1 Major: Zeitschr. f. Kinderh., 1913, viii, 340. 

2 Pisek and Lewald: loc. cit. 

3 Mosenthal: Arch. Ped., 1909, xxvi, 761. 

4 Pfaundler: Magencapacitat im Kindesalter: Stuttgart, 1898, quoted by 
Gundobin. 

5 Holt: Dis. Infancy and Childhood, N. Y. and London, 1911, 309. 



AND INFANT FEEDING 









TABLE 


3 








Age 


No. of 


Capacity 


Age 


No. of 


Capacity 


cases 


oz. c. c. 


cases 


oz. c. c. 


Birth 


5 


1.2 


36 


7-8 mos. 


9 


6.88 


200 


2 weeks 


7 


1.5 


42 


10-11 mos. 


7 


8.14 


244 


4 " 


4 


2.0 


60 


12-14 mos. 


10 


8.90 


265 


6 " 


11 


2.27 


68 










8 " 


4 


3.37 


100 










10 " 


2 


4.25 


128 










12 " 


6 


4.50 


132 










14-18 wks. 


12 


5.00 


150 










5-6 mos. 


14 


5.75 


172 


1 









than the latter. The following table is a summary of the results 
which he obtained in a study of twenty-four cases : 



TABLE 4 

Amount of milk offered at each nursing 4.0 oz. 

Amount of milk ingested at each nursing 3.6 oz. 

Post mortem gastric capacity (Pfaundler's method) 2 . 6 oz. 

" In every instance, excepting the diastolic stomachs, the infant 
ingested more fluid at a nursing than the volume of its stomach, as 
determined by careful measurements, can contain." This means 
that the figures for gastric capacity given above represent the ana- 
tomic capacity of the stomach, and that the physiologic capacity, 
what an infant can take at a nursing, can be considerably larger 
than this. This can be explained by the fact that shortly after 
milk is swallowed the stomach shows signs of motor activity and 
the milk begins to pass almost immediately into the intestines. 
This is proven by fluoroscopic examination which shows the milk 
spurting through the pylorus into the intestine before the meal is 
finished. This happens more easily with human milk than it 
does with simple dilutions of cow's milk. 

Duration of Stomach Digestion. — The duration of stomach 
digestion has been studied for a long time, at first with the stomach 
tube, 1, 2 * 3 » 4 » 5 only, and recently with the Roentgen ray. 6, 7 It 

1 Epstein: Prager med. Wochenschr., 1880, 45, 450. 

2 Epstein: Prager med. Wochenschr., 1881, 33-34. 

3 Epstein: Jahr. f. Kinderh., 1887, xxvii, 113. 

4 Czerny: Prager med. Wochenschr., 1893, 495, u. 510. 

6 Wohlmann: Jahr. f. Kinderh., 1891, xxxii, 297. 

8 Tobler and Bogen: Monat. f. Kinderh., 1908-1909, vii, 12. 

7 Leven and Barret: Presse Medicale, 1906, 63, 503. 



6 DISEASES OF NUTRITION 

can be said in general on the basis of these observations, that 
the stomach digestion lasts in the breast-fed baby from one and a 
half to two hours, and in the artificially-fed baby three hours. 
Pisek and Lewald believe that a large number of stomachs practi- 
cally empty themselves within an hour, while A. H. Meyer, 1 and 
Von Monrad think that it is three and one-half hours before the 
stomach is emptied. A large meal obviously requires a longer 
period for digestion than a smaller one, and cow's milk remains 
longer in the stomach than human milk. 2 

Ladd's 3 extended series of observations on babies, and Cannon's 4 
on animals, have done much to increase our knowledge of this 
complicated subject. The infant's stomach, as compared with 
the adult's, shows a "curious lack of peristalsis." Shortly after 
food is ingested some of it may be discharged into the duodenum, 
without undergoing stomach digestion. It has been found in 
animals that carbohydrates leaVe the stomach the most rapidly 
of the three food components, a large part of them being discharged 
within two ho^rs, while proteins are discharged less rapidly, and 
fat the most slowly. These facts fit in with the economy of the 
body, since carbohydrates are not digested at all by the gastric 
juices, and are, therefore, passed along to the small intestine as 
quickly as possible; whereas the proteins, which are digested by 
the gastric juices, are retained for this action. The fats, on the 
other hand, are discharged from the stomach at such a slow rate 
that there is never any great accumulation of fat in the small 
intestine, the rate of the discharge from the stomach being ap- 
proximately the same as that of the departure of fat from the small 
intestine. The discharge of mixtures of food depends upon the 
relative proportions of fat, carbohydrate and protein which they 
contain (Cannon). These findings in animals have been partially 
confirmed in a few observations on infants. In one instance, how- 
ever, in which the infant received a food containing no fat, 6.62% 
sugar, and 3.5% protein, the stomach was not empty at the end 
of 7J^ hours. If, however, a fresh feeding is given before the 
stomach is empty, the bismuth feeding is frequently pushed out 
into the small intestine by the second meal. Tobler and Bogen 5 
also found that milk mixtures containing much cream pass more 

1 Meyer, A. H.: Bibliothek f. Laeger, 8, R, III, 390-512. Kopenhagen 
1902. Ref . im Jahr. f . Kinderh., 1903, u, Folge, lviii, 275. 

2 Tobler and Bogen: Monat. f. Kinderh., 1908-1909, vii, 12. 

3 Ladd: Am. Jour. Dis. Children, 1913, v, 345. 

4 Cannon: The Mechanical Factors of Digestion, London and N. Y., 1911. 
6 Tobler and Bogen: Monatschr. f. Kinderh., 1908-1909, vii, 12. 



AND INFANT FEEDING 7 

slowly through the pylorus than those with low percentages of 
fat. 

Gastric Motility. — The motility of the stomach is in inverse 
proportion to the concentration of the food; in other words, the 
greater the dilution of the milk, the more rapidly the organ empties 
itself. 1 In animals, the stomach is found to show signs of motor 
activity shortly after milk has been swallowed. According to the 
character of the movements of the gastric wall, two regions may 
be distinguished. The movements of the left hand, or cardiac part 
of the stomach, consist of slow, shallow, peristalsic waves, which 
gently push the food lying next to the gastric wall toward the py- 
lorus. The cardiac part of the stomach acts as a reservoir, where 
the food lies undisturbed by any movement except such as is neces- 
sary to pass the peripheral layer on to the pyloric half. The state 
of affairs is different in the right half of the stomach. Five to eight 
minutes after the ingestion of food, deep peristaltic rings advance 
toward the pylorus and press the gastric contents strongly against 
the pyloric valve. The valve opens from time to time and allows 
some of the food to pass into the small intestine. 2 ' 3 It has thus 
been shown by Cannon, in his Roentgen ray work on cats, that the 
two parts of the stomach have two distinct functions, the left, or 
cardiac half, acting as a reservoir, in which the food lies practically 
undisturbed until it is passed on to the right or pyloric portion. 
Here it is thoroughly mixed under greater pressure, and is finally 
pushed into the small intestine. 

Tobler 4 was able to show, in a boy with a gastric fistula, that 
the coagulation of casein begins in from two to three minutes and 
is complete in ten minutes. This process is of great importance, 
since it is found that the fluid portion, containing the milk sugar 
in solution, is rapidly expelled from the stomach, while the curd, 
containing casein with fat entangled in its meshes, remains behind 
for further digestion. 5 Nature thus provides that too much fat 
is not set free at one time. The fluid gastric contents begin to 
pass through the pylorus before the infant has stopped nurs- 
ing. 

The cardiac end of the stomach has a very delicate mechanism 
of its own by means of which it is at times closed, at others open. 
In cats the cardia is alkaline. As soon as it becomes acid, the car- 

1 Clark: Am. Jour. Med. Sciences, May and June, 1909, 674, 872. 

2 Cannon: Am. Jour. Phys., 1898, 1, 359. 

3 Cannon: Am. Jour. Med. Sciences, 1906, cxxxi, 563. 

4 Tobler: Verhandl. d. Gesell., Kinderh., 1906, xxiii, 144. 

5 Moritz: Zeitschr. Biol., 1901, xlii, 565. 



8 DISEASES OF NUTRITION 

diac orifice closes and remains so until the neighboring food com- 
ponents become alkaline. 1 The pyloric valve acts in a manner 
directly opposed to that at the cardia. ,When the material in the 
antrum pylori is acid, the valve opens and vice versa. 2 

On the duodenal side of the pyloric valve an alkaline reaction 
allows the valve to open and an acid reaction causes it to close. 
Cowie and Lyon 3 found that the opening and closing reflex of the 
pyloric valve could also be demonstrated in infants. When the 
food was made acid the duodenal closing reflex is sustained and 
the evacuation of food from the stomach is consequently delayed, 
even if the stomach contents are acid. Strongly alkaline food, on 
the other hand, causes the pyloric opening reflex to be delayed 
and as a result the food is retained longer in the stomach. Free 
hydrochloric acid is not necessary for pyloric opening in the in- 
fant, and it may provoke prolonged closing from the duodenal 
reflex. 

Solid particles of food may be pushed against the pylorus with- 
out opening the valve 4 and it is supposed that the curd of milk will 
have considerable mechanical influence on the opening and closing 
of the pylorus, while fat, whey, and lactose have little or no me- 
chanical action. Tobler 4 has also shown that the rapid inflation of 
a balloon in the duodenum checks the passage of food from the 
stomach. Cannon 5 believes that the evidence is opposed to the 
conception that mechanical agencies, acting either in the stomach 
or in the intestine, play an important part in controlling the normal 
gastric evacuation. 

Secretion of the Stomach. — Pepsin has been found in the 
stomachs of fetuses born at four and at six months, 6 ' 7 and is always 
present in the stomachs of babies born at term. 8 Breast-fed babies 
secrete less pepsin than artificially-fed babies. Rennin is prac- 
tically always present at birth. 9 Heubner 10 found lactic acid in 
babies' stomachs, but Sotow 11 and Hamburger and Sperk were 

1 Cannon: Am. Jour. Phys., 1908, 1909, xxiii, 105. 

2 Cannon: Am. Jour. Med. Sciences, 1906, cxxxi, 563. 

3 Cowie and Lyon: Am. Jour. Dis. Children, 1911, ii, 252. 

4 Tobler: Zeitschr. Physiol. Chem., 1905, xlv, 185. 

5 Cannon: The Mechanical Factors of Digestion, London and New York, 
1911. 

6 Langendorff: Arch. f. Anat. u. Physiol., 1879. 

7 Huppert: Wiener Sitsungsberichte, 81, Abt. 3. 

8 Zweifel: Untersuchungen iiber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 

9 Hamburger and Sperk: Jahr. f. Kinderh., Neue Folge, 1905, lxii, 495. 

10 Heubner: Jahr. f. Kinderh., 1891, xxxii, 27. 

11 Sotow: Diss. St. Petersburg, 1895. 



AND INFANT FEEDING 9 

unable to confirm these findings. A. H. Meyer explained these 
conflicting results when he found that lactic acid appeared within 
two hours after the feeding of mixtures of cows' milk, and that it 
never appeared after a test meal of tea, or a "water meal." This 
makes it practically certain that the lactic acid found in the 
stomach is not the result of gastric secretion, but of the action of 
the stomach juices or of bacteria on the food. 

Engel * studied an infant of four weeks with a fistula in the 
upper duodenum, in which the connection between the stomach 
and duodenum was apparently cut off. The infant received noth- 
ing by mouth. Engel was able to collect from 100 to 200 cubic 
centimeters of gastric secretion per day by means of a small rubber 
tube passed through the mouth, and found in this pepsin, rennin, 
and free Irydrochloric acid. He was unable to demonstrate a fat- 
splitting ferment or lactic acid. There is a difference of opinion 
concerning the presence of fat-splitting ferments in the stomach of 
infants from birth onward. Sedgwick 2 removed the stomach con- 
tents and found that they were able to split fat. This property is 
present at birth in rabbits and at a very early age in babies (in one 
case at two weeks). Hess 3 found lipase in the stomach of the unfed 
new-born infant. As much as 25% of the fat in the food can be 
split by the gastric juices, although it is believed that under normal 
conditions less than this is split. In infants between one and four 
months old, the lipase content of the stomach increases with the 
age of the infant. 4 

« Kramsztyk 5 found trypsin in a small proportion of the infants 
to whom oil test meals had been given. It is believed that this 
trypsin has its origin in the pancreas and is regurgitated into the 
stomach. (Ibrahim.) 

Practically all of the factors present in the adult digestion are 
present in babies, but in a weaker form. 

Free Hydrochloric Acid. — Free hydrochloric acid is never 
found in the stomachs of some healthy breast-fed infants 6 while 
in others it is found regularly. 7 Hess 8 found it regularly in the 

1 Engel: Archiv. f. Kinderh., 1909, xlix, 16. 

2 Sedgwick: Jahr. f . Kinderh., 1906, lxiv, 194; also, Arch. Ped., 1906. 

3 Hess: Am. Jour. Dis. Children, 1913, vi, 264. 

4 Hahn: Am. Jour. Dis. Children, 1914, vii, 305. 

6 Kramsztyk: Przeglad Pedyatryczny, 1909, i, 209. 

6 Heiman: Arch. Ped., 1910, xxvii, 570; Labbe: Rev. mens, des mal de 
l'enfance, 1897, xv, 401. 

7 Cassel: Arch. f. Kinderh., 1890, xii, 175; Wohlmann: Jahrb. f. Kinderh., 
1891, xxxii, 297. 

8 Hess: loc.cit. 



10 DISEASES OF NUTRITION 

stomachs of new-born infants even before food was given. Whether 
free hydrochloric acid is found or not in a given instance seems to 
depend upon the technique of the investigator. It may be said, 
in general, that the longer after a meal the stomach contents are 
tested, the more frequently hydrochloric acid is found. It is ob- 
vious that when a baby receives a food containing much casein, 
free hydrochloric acid will appear much later than when it receives 
a food which contains but little casein or other material with which 
hydrochloric acid can combine. 

Dundin 1 found that the reaction of the gastric mucous mem- 
brane of the fetus was always neutral up to the sixth month, 
after which it was acid. He was unable, however, to demonstrate 
free hydrochloric acid in any fetus. Hamburger and Sperk 2 
found small amounts in the stomachs of new-born babies from 
the third to the eighth day. The amount increases with the age 
of the baby (A. H. Meyer). About three times as much becomes 
" combined acid" on artificial feeding as on breast feeding. The 
acidity immediately after a meal is nil, but steadily increases dur- 
ing digestion, the rapidity of the increase varying directly with 
the age of the child. Free hydrochloric acid appears in a few 
minutes after a feeding of barley water. It does not appear, how- 
ever, for an hour or more after a feeding of milk, the delay being 
due to the power of casein to absorb and combine with acid. Free 
acid appears later in disease than in health. 3 It is interesting to 
note that the breaking down of sugar into lactic acid is retarded 
by the presence of from .01% to .02% of hydrochloric acid and 
prevented by .07% to .08%. The power of casein to delay the 
appearance of free hydrochloric acid explains the fact that lactic 
acid is frequently present in the stomachs of babies fed on cows' 
milk. 4 ' 5 ' 6 

The recent studies of Hahn 7 of the hydrogen-ion concentration 
of the gastric contents have added light from another point of 
view. He found that the acidity of the stomach juices, when stud- 
ied in this manner, was strikingly constant being (H) = 1.0X10" 5 . 
This is in striking contrast to the figures given above of the titrable 
acidity, and is considered to be the normal acidity of the stomach 

1 Dundin: quoted by Gundobin, Die Besonderheiten des Kindesalter, 
Berlin, 1912, 269. 

2 Hamburger and Sperk: Jahrb. f. Kinderh., 1905, lxii, 495. 

3 Clark: Am. Jour. Med. Sciences, May and June, 1909, 672, 872. 

4 Sieber: Nad. Jour. f. prakt. Chemie, 1879, xix, 433. 

5 Cohn, F. O.: Zeitschr. f. Phys. Chem., 1890, xiv, 75. 

6 Hirschfeld: Pfluger Arch., 1890, xlvii, 510. 

7 Hahn: Am. Jour. Dis. Children, 1914, vii, 305. 



AND INFANT FEEDING 11 

contents at the height of digestion, when the food is either one- 
third or two-thirds milk. He believes that this is the optimum 
acidity for the action of rennet and gastric lipase and that it in- 
hibits the action of pepsin. 

Our conception of the therapeutic action of alkalies in modifying 
gastric digestion has recently been changed. It has been claimed 
by Southworth * and others, on the basis of the work of Van Slyke 
and Hart, that lime water and sodium bicarbonate neutralize the 
hydrochloric acid secreted in the stomach, and thus delay the 
coagulation of milk by rennin. As the result of this delay a por- 
tion of the milk is allowed to pass into the duodenum before co- 
agulation takes place. The amount of alkali given should be cal- 
culated in relation to the amount of milk and cream used in the 
mixture and not to the total quantity of the mixture, because the 
milk and cream alone contain casein and it is the casein which is 
acted upon by the rennin. This seems to be the most reasonable 
view to take at present. Clark 2 claims, however, that lime water 
does not reduce the acidity of the gastric contents, and that the 
neutralization of a portion of the acid is overcome by an increased 
stimulation of the gastric glands to form hydrochloric acid. The 
amount of acid available for digestion may thus be even increased. 
These findings presumably apply also to bicarbonate of soda. The 
evidence in relation to this subject is conflicting and it is by no 
means certain that the present conception of the action of alkalies 
will not be greatly modified by future investigations. The action 
of sodium citrate has recently been shown by Bosworth (see 
chapter on Chemistry of Cow's Milk) to be dependent in large 
part on reactions that occur in the milk itself. It changes the 
compound known as calcium caseinate into sodium caseinate. 
Sodium caseinate is changed by rennin to sodium paracaseinate, 
which is soluble, while calcium paracaseinate, which is formed 
from calcium caseinate, is insoluble. Coagulation by rennin is 
thus prevented. To what extent sodium citrate may also com- 
bine with the hydrochloric acid of the stomach to form sodium 
citrate and thus reduce the amount of " available hydrochloric 
acid," is unknown. 

Rennin: (Chymosin). — The rennin ferment has been found 
in the stomach on the first day of life. 3 It causes the coagulation 
of milk. It is in the form of a pro-ferment in the gastric mucous 
membrane, which is inactive until it has come into contact 

1 Southworth: Arch, of Pediatrics, Feb., 1905, p. 131. 

2 Clark: loc.cit. 

3 Szydlowski: Jahrb. f. Kinderh., 1892, xxxiv, 411. 



12 DISEASES OF NUTRITION 

with hydrochloric acid. 1 According to Hahn 2 it works best with 
a hydrogen-ion concentration (H) = 1.0xl0* 5 . Some writers, 3,4 
believe that rennin and pepsin are identical, because it has been 
impossible to separate the two enzymes by obtaining specific anti- 
bodies for them. There is not sufficient evidence available to 
settle this question. 

Pepsin. — Pepsin has been extracted from the gastric mucous 
membrane of a four months' old fetus 5 and is usually present at 
all ages in both health and disease. 6 Healthy breast-fed infants 
seem to produce less than healthy artificially-fed infants of the 
same age. The amount increases from birth until the end of the 
third month of life, after which it remains constant. Older babies 
of less than the normal weight produce the amount of pepsin which 
corresponds to their ages. 7 The stomachs of babies with severe 
chronic disturbances of nutrition frequently contain no pepsin. 
When these babies improve in health and gain in weight, their 
stomachs again contain pepsin. The stomach juice of normal in- 
fants is capable of transforming protein into peptone. 8, 9 Pepsin 
is present in the gastric glands as pepsinogen (Glassner), which 
is converted by hydrochloric acid into pepsin. An hydrochloric 
acid extract of the gastric mucous membrane quickly loses its 
power of peptonization when the acid is neutralized with soda. 

Absorption in the Stomach. — Most of the direct experiments 
on gastric absorption have been done on animals and indirect 
methods have to be depended upon in babies. Pfannenstill 10 found 
that iodine appeared in the urine of healthy breast-fed babies in 
from fifteen to twenty-five minutes after it was given by mouth. 
These results have been confirmed by other observers. Gundobin n 
found that the absorptive power of the stomach (for KI) was dimin- 
ished in disease in direct proportion to the severity of the disease. 
For example, in "dyspepsia" potassium iodide was absorbed on 
the average in 17.1 minutes, in " gastro-enteritis " in 24^ minutes, 
and in " cholera infantum" in 34.9 minutes. According to Can- 

1 Glaessner: Beitr. zur chem. Physiol, u. Path., 1902, i, 24. 

2 Hahn: Am. Jour. Diseases of Children, 1914, vii, 305. 

3 Pawlow and Parastschuk: Zeitschr. f . Physiol. Chemie, 1904, xlii, 415. 

4 Blum and Boehme: Hofm. Beitr. z. chem. Physiol, u. Path., 1907, ix, 74. 

5 Langendorff : Arch. f. Anat. u. Physiol., 1879, 95. 

6 Clark: loc. cit. 

7 Rosenstern: Berliner klin. Woch., 1908, xlv, 542. 

8 Ramsey: Arch. Ped., May, 1909, 341. 

9 Langstein: Jahr. f. Kinderh., 1906, Neue Folge, lxiv, 139. 

10 Pfannenstill: Nord. med. Archiv., 1892, Neue Folge, ii Heft 10. 

11 Gundobin: Die Besonderheiten des Kindesalters, Berlin, 1912, 272. 



AND INFANT FEEDING 13 

non 1 absorption is an associated function of the churning action 
in the vestibule of the stomach. " Although water is not absorbed 
in the stomach, glucose in concentrated solution, and proteins 
which have been exposed to gastric digestion, may be absorbed 
in considerable amount (V. Mering and Tobler). The mucosa 
of the vestibule has fewer glands than the mucosa of the cardiac 
end, where they are placed in very close order. The absorption 
that occurs in the stomach probably takes place, therefore, in 
the vestibule, for there the epithelial surface is most favorable 
to the process. There also gastric digestion is most advanced, 
and the food in consequence is most ready for passage through the 
mucosa. Furthermore, the mechanical conditions in the vestibule 
are most favorable to absorption because the digested food is re- 
peatedly brought into very close contact with the mucous lining. " 

PANCREAS 

The weight of the pancreas increases in general parallel with 
the body weight. Taking average figures, the increase of weight 
in intra-uterine life is relatively rapid, so that it is forty times 
larger at birth than it is at the third month of fetal life. After 
birth it doubles in weight in from three to four months, at the 
same time increasing its functional activity proportionately. 
The increase in weight from this time on is slower. 

The table of Hartge 2 on page 14 (Table 5) gives the weightaand 
measurements of the pancreas: 

The pancreatic secretions contain three digestive ferments, 
namely, trypsin which splits up protein, amylopsin which changes 
starch into sugar, and steapsin which splits neutral fat into fatty 
acids and glycerin. All these ferments are probably present in 
the pancreas of the human fetus from the third month of fetal life 
onward. At birth the amount of trypsin and steapsin is less than 
in the adult, and amylopsin is always found during the first week 
of life and increases in amount with the age of the infant. 3 * 4> 5> 6 
In chronic diseases such as congenital syphilis and " enterocolitis" 
there may be an interstitial pancreatitis with a corresponding 

1 Cannon: The Mechanical Factors of Digestion, New York and London, 
1911, 68. 

2 Hartge: The Pancreas of the Foetus and Newborn: Diss. St. Petersburg, 
1900 (Russian), quoted by Gundobin. 

3 Hess: Am. Jour. Dis. Children, 1912, ii, 205, Summary of Literature. 

4 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

5 Ibrahim and Gross: Ref. Deut. med. Wochenschr. Vereinsbeilage, 1908, 
xxv, 1128. 

6 Hartge: loc. cit. 



14 



DISEASES OF NUTRITION 



TABLE 5 



Age 


Number of 


Wt. in 


Average 
length in 


Width in 


Thickness in 




cases 


grammes 


cm. 


cm. 


cm. 


3 mos. fetus 


1 


0.07 


1.1 


0.4 -0.2 




4. " << 


2 


0.145 


1.65 


0.75-0.27 


0.33-0.17 


5 " " 


3 


0.38 


3.2 


0.8 -0.5 


0.34-0.21 


6 " " 


6 


0.38 


3.2 


0.8 -0.48 


0.38-0.25 


y u u 


2 


0.76 


4.35 


1.0 -0.63 


0.4 -0.25 


8 " " 


2 


1.18 


4.32 


1.2 -0.7 


0.6 -0.35 


9 " " 


4 


1.63 


5.7 


1.5 -0.85 


0.58-0.35 


1-2 months 


3 


2.61 


6.93 


1.6 -0.9 


0.66-0.56 


2-3 


3 


2.64 


7.54 


1.6 -0.9 


0.65-0.5 


3-4 


3 


4.93 


7.46 


2.1 -1.5 


0.8 -0.57 


4-5 


3 


5.4 


7.5 


2.25-1.5 


0.85-0.8 


5-6 


3 


5.28 


7.0 


1.75-1.25 


0.95-0.65 


6-9 


3 


7.37 


8.2 


2.0 -1.6 


1.0 -0.65 


9-12 " 


3 


8.67 


9.5 


2.0 -1.2 


0.9 -0.45 



weakening of the pancreatic ferments (Gundobin). Hess 1 has 
shown that lipase (steapsin) may be deficient in acute intestinal 
indigestion while the two other pancreatic ferments are present in 
considerable amounts. 

The secretin of the intestinal mucous membrane stimulates the 
production of the pancreatic ferments. Bayliss and Starling 2 
showed that when inorganic or organic acids were discharged from 
the stomach into the duodenum secretin was set free. When se- 
cretin is carried by the blood to the pancreas it starts the pancreatic 
secretion. Secretin has been found in the fetus and in many new- 
born babies. The peptic ferment, trypsin, is present in the pancreas 
as the pro-ferment trypsinogen. Many fetuses have trypsinogen, 
but no trypsin. The secretion of enterokinase is called forth by the 
pancreatic juice and has been demonstrated in new-born and pre- 
mature babies by Ibrahim. The pancreatic ferments, with the 
added action of erepsin, carry the digestion of proteins from 
albumoses and peptones into amino acids. 

The fat-splitting ferment, called lipase or steapsin, is active in 
acid, alkali, or neutral surroundings. This ferment is present in 
the pancreatic juice in part as a pro-enzyme, which is changed by 
the bile into steapsin. The bile in this way increases the fat-split- 
ting power of the pancreatic ferments 3 and facilitates emulsion. 

1 Hess: Am. Jour. Dis. Children, 1913, v, 268. 

2 Bayliss and Starling: Jour. Physiol., 1902, xxviii, 325-53, 1903, 174. 

3 Furth and Schutz: Hofm. Beit. z. chem. Physiol, u. Path., 1907, ix, 28. 



AND INFANT FEEDING 



15 



There is no work upon the sugar-splitting ferments in babies 
other than that of Ibrahim, 1 Miura, 2 neither of whom are able 
to find any in the new-born. 



LIVER 

The weight of the liver post mortem depends upon whether 
or not it is full of blood. When the former weight is taken, it 
is known as the " physiological weight/' and the latter as the 
"post mortem weight." The physiological weight is obtained by 
filling the liver to its maximum with water, after it has been re- 
moved from the body. 

The following table of Kowalski' s 3 gives the weights of the livers 
of fifty normal infants : 

TABLE 6 



Age 


No. of cases 


Total wt. of liver 


Body weight in 






in grammes 


grammes 


5 mos. fetus 


1 


39 


650 


ij a ii 


1 


70 


1,320 


%y 2 " " 


1 


110 


2,000 


9 " " female 


1 


100 


1,900 


9 " " male 


2 


92 


2,000 


New-born 


3 


130 


3,000 


1-7 days 


4 


133.5 


3,150 


2-3 mos. 


6 


187.5 


4,075 


3-4 " 


4 


259 


4,350 


4-5 " 


2 


248 


5,900 


8-10 " 


2 


320 


7,000 


15 " 


2 


325 


10,000 



The weight of the liver in comparison with that of the body is 
4.33% in the new-born and 2.85% in the adult. The function of 
the liver is to manufacture bile and to change carbohydrates, 
proteins and fats into glycogen. 4 Its cells also play an important 
part in the formation of urea. 

Bile. — The composition of bile, according to Geptner, 5 is as 
follows : 

1 Ibrahim: Verhandl. d. Gesell. fur Kinderh. Koln., 1908, 21. 

2 Miura: Zeitschr. f. Biologie. 32 Neue Folge, 1895, xiv, 266. 

3 Kowalski: Die Leber des Kindes. Diss. St. Petersburg, 1900 (Russian), 
quoted by Gundobin. 

4 Kowalski : loc. cit. 

5 Geptner: Die Chemische Zusammensetzung der Galle des Kindes. Diss. 
St. Petersburg, 1900 (Russian), quoted by Gundobin. 



16 



DISEASES OF NUTRITION 
TABLE 7 



Age 


Amount 


Composition of the bile 






Water 


Solids 


Mucin 


Bile 

salts 


Sodium 
glyco- 
cholic 
acid 


Sodium 

tauro- 

cholic 

acid 


Choles- 
terin, 

Fat. Le- 
cithin 


Mineral 
salts 




Per cent 


93.54 


6.46 


1.56 


2.35 


1.40 


0.90 


1.86 


0.53 


Infants 


of 100 parts 
of dry sub- 
stance 




100 


25.23 


35.09 


21.22 


13.11 


28.44 


8.08 




Per cent 


91.87 


8.13 


1.54 


3.32 


2.21 


1.06 


2.26 


0.86 


12-18 

months 


of 100 parts 
of dry sub- 
stance 




100 


19.13 


40.88 


27.11 


13.16 


27.18 


10.89 




Per cent 


87.61 


12.37 


1 98 


6.38 


3.49 


1.57 


1.99 


0.82 


Adults 


of 100 parts 
of dry sub- 
stance 




100 


16.0 


51.57 


28.21 


12.69 


16.09 


6.62 



The bile salts are of importance in activating the pancreatic 
juices and in acting with them in splitting the fat. The liver, be- 
sides secreting the bile, acts as a protection against bacterial and 
other poisons. 1 

INTESTINES 

The length of the intestinal tract increases fairly regularly with 
the age of the infant. 

The table on page 17 is the result of measurements by Debele: 2 

Small Intestine. — The juices of the small intestine contain 
invertin (Ibrahim), both in the fetus and in the new-born. Sev- 
eral writers, 3, 4> 5 have demonstrated erepsin in the fetus and other 
ferments have been identified by other writers. 

Carbohydrates are split into monosaccharides in the small intes- 
tines, where they are absorbed. The specific ferments, invertin, 
lactase, and maltase convert the corresponding sugars into mono- 

1 Uffenheimer: Ergebnisse d. inn. Med. et Kinderh., 1908, No. 2, 271. 

2 Debele: Die Lange des Darmkanals im Kindesalter. Diss. St. Petersburg, 
1900 (Russian), quoted by Gundobin. 

3 Langstein and Soldin: Jahrb. f . Kinderh., 1908, Neue Folge, lxvii, 9. 

4 Jaeggy: Zentralblatt f. Gynak., 1907, No. 35, 1060. 

5 Foa: Munch, med. Wochenschr., 1907, 2201. 



AND INFANT FEEDING 



17 



TABLE 8 







Length of trunk 








Number of 


from the 7th 


Length of the 


Length of the 


Age 


cervical vertebra 


small intestine 


large intestine 




cases 


to the coccyx 
in cm. 


in cm. 


in cm. 


1 month 


4 


21.5 


296.4 


63.3 


1-2 mo8. 


6 


21.1 


319.1 


65.1 


2-3 " 


14 


22.2 


358.1 


70.6 


3-4 " 


5 


23.1 


379.4 


71.2 


4-5 " 


4 


25.5 


383.4 


72.3 


5-6 " 


5 


25.1 


380.3 


69.2 


7-9 " 


2 


27.0 


412.4 


80.5 


6-12 " 


6 


27.0 


419.8 


83.9 


Average 


46 


23.5 


365.3 


71.6 



saccharides and are either present in the digestive juices or in the 
mucous membrane. Food stays a relatively short time in the 
small intestine, but during that time is mixed with and acted upon 
by the digestive juices so that it is ready for absorption before it 
reaches the large intestine. 

There is nothing definitely known about the secretions of the 
large intestine. 



18 DISEASES OF NUTRITION 



CHAPTER II 
THE DIGESTION AND METABOLISM OF FAT * 

The fat in the infant's food is principally in the form of neutral 
fat. Saliva has no action upon it, and, although saponification 
begins in the stomach, it probably is not carried on to a point 
which influences to any degree the future digestion of the fat. The 
action of the fat-splitting ferment of the stomach is eventually 
stopped entirely by the acid reaction of the stomach contents. The 
action of the gastric secretions is of importance indirectly, because 
when milk is coagulated by rennin, most of the fat is ensnared in 
the meshes of the casein curds, and the casein coating must be first 
digested before the digestive juices can reach the fat. There is, 
therefore, very little opportunity for the absorption of fat in the 
stomach. This ensnaring of the fat by the casein may be of phys- 
iological importance in preventing the liberation of too large an 
amount of fat in the intestinal canal at one time. 

Fat has a definite influence on the emptying time of the stomach, 
large amounts tending to delay it. 2 Large amounts of fat in the 
food are, according to Tobler 3 of etiological significance in the 
pathogenesis of pyloric spasm. He found in the stomach of one 
infant more fat than had been given to it during the previous 
twenty-four hours. He also calculated that one litre of milk would 
cause one and a half litres of digestive juices to be secreted. 

The real digestion of fat commences when it reaches the small 
intestines, where it undergoes a physical change. The fat is 
first of all subdivided by the alkaline salts of the bile, and of the 
pancreatic and intestinal juices. Fatty acids, which are formed 
as the result of the action of the fat-splitting ferments, react with 
the alkaline carbonates present to form soaps. The soaps which 
result make the fat particles still smaller and form an emulsion. 

Absorption. — There is considerable evidence to show that 
neutral fat (unsplit fat), is not absorbed as such into the intes- 

1 Tobler and Bessau: AUegemeine Pathologische Physiologie der Ernahrung 
und des Stoffwechsels im Kindesalter, Wiesbaden, 1914, has been consulted 
and quoted freely in this section. 

2 Tobler and Bogen: Monatsschr. f. Kinderh., vii, 12. 

3 Tobler: Verhandl. d. Gesellschaft f. Kinderh., 1907, 411. 



AND INFANT FEEDING 19 

tinal wall : for example, hydrous wool fat and paraffin, which may- 
be made into emulsions but cannot be split, are not absorbed. 1 
It has also been shown by animal experimentation that the amount 
of fat in the chyme is directly proportional to the amount of fat 
which has been split. 2 It is also taught by some that fat is ab- 
sorbed both in the form of an emulsion and in the form of water- 
soluble soaps, neither view excluding the other. 

Bloor 3 found that substances similar to food fat in that they 
emulsified well, were soluble in fat solvents and were liquid at 
temperatures below that of the body, but could not be converted 
into a water soluble form, and were not absorbed at all in the intes- 
tinal canal. He concluded that the slow passage of fats from the 
stomach, the abundant provisions for hydrolysis and for the ab- 
sorption of fat-like substances which cannot be changed to a water 
soluble form, make it extremely probable that saponification is a 
necessary preliminary to absorption. The significance of the 
mechanism involved is little understood, but one of its uses would 
appear to be to exclude undesirable fat-like substances which 
would otherwise be carried in with the fats. 

Kastle and Loevenhart 4 demonstrated the almost universal 
presence of lipase in the tissues, and showed that this ferment 
could reverse its action. That is to say, it can synthesize or change 
soaps back into neutral fats as well as split neutral fats and form 
soaps. It is, therefore, possible that the soaps, which have been 
formed during the digestion, may be changed back during their 
passage through the intestinal epithelium by the reversible action 
of lipase into neutral fat, because neutral fat is found almost exclu- 
sively in the lymph stream. Whitehead's 5 experiments on cats 
seem to strengthen this statement, because he found that butter- 
fat stained with Sudan III lost the stain during absorption (soaps 
will not stain with Sudan III) ; Sudan-staining fat was seen in the 
lumen of the intestine; none was seen in the intestinal epithelium 
and a Sudan-staining fat was again found in the lacteals of the villi. 

Noll 6 and Wilson 7 conclude from their studies with animals that 
the epithelium of the intestinal mucous membrane plays a part in 
the absorption of fat. The emulsified fat is taken up into the 

1 Connstein, W.: Arch. f. Anat. u. Physiol., 1899, 30; Henriques and 
Hansen: Zentralblt. f. Physiol., 1900, xiv, 313. 

2 Levites: Ztschr. f. physiol. Chem., xlix, 273; liii, 349. 

3 Bloor: Jour. Biol. Chem., xv, 105, and Jour. Biol. Chem., 1914, xvi, 517. 

4 Kastle and Loevenhart: Am. Chem. Jour., 1900, xxiv, 491. 

5 Whitehead: Am. Jour. Physiol., 1909, xxiv, 294. 

6 Noll: Arch. ges. Physiol., cxxxvi, 208. 

7 Wilson: Trans. Canadian Inst. Sept., 1906, viii, 241. 



20 DISEASES OF NUTRITION 

striated cells bordering the villi. These cells contain a considerable 
amount of fat before the fat can be detected in the lacteals. A 
stage is then reached in which the fat content of the mucosa further 
increases and at the same time removal through the lacteals sets 
in. The fat is then found in the lacteals until all the fat has been 
removed from the epithelial cells. There is hardly any evidence 
to show that the fat can be carried from the epithelial cells to the 
lacteals by leucocytes. Samelson * has found a fat-splitting enzyme 
in the blood of infants. It is probable that most of the fat which 
is absorbed goes into the thoracic duct and from there is poured 
into the blood stream. The fate of a not inconsiderable portion 
of the absorbed fat has not yet, however, been determined. 

When the fat has entered the blood stream it can be demon- 
strated by the ultra microscope. When fat is present in the blood 
after food has been taken, the condition is called digestion lipemia. 
It commences two to three hours after meals and disappears after 
seven to eight hours. 2 The height of the curve is dependent on the 
amount of fat in the food, and also on the age and condition of the 
infant. The absorption of fat is extraordinarily good in health in 
babies fed on cow's milk as well as in those fed on human milk. 
It is usually over 90% and may be as high as 98% of the fat in- 
gested; 3 8% to 11% of the ingested fat is absorbed in the upper 
part of the small intestine 4 and the absorption of fat is nearly com- 
plete at the ileocecal valve. 4 The large intestine is capable of 
absorbing fat in large amounts under special favorable condi- 
tions, 5 but under ordinary circumstances absorption here is prob- 
ably very slight. 

The results of estimations of the amount of fat in the stools 
of babies in starvation and in health make it probable that the 
greater part of the fecal fat comes from the food and not from the 
intestinal secretions. 6 It is evident, therefore, that the study of 
the fat in the stools with the microscope will give valuable infor- 
mation about the digestion. It is necessary first to know how much 

1 Samelson: Zeitschr. f. Kinderh., 1912, iv, 205. 

2 Neumann: Wien, klin. Wochenschr., 1907, 851; Schelble: Munchen med. 
Wochenschr., 1908, No. 10, p. 492; Bahrdt: Breslauer Tagung der Freien Ver- 
einigung fur wissenschafthche Padiatrie, 1908, Monatschr. f. Kinderh., vii, 
106. 

3 Czerny and Keller: "Des Kindes Ernahrung, Ernahrungstorungen und 
Ernahrungs therapie," Leipzig u. Wien, 1906, I, 263; Freund: Ergebn. d. inn. 
Med. u. Kinderh., 1909, hi, 139. 

4 Levites : loc. cit. 

5 Hamburger, H. J.: Engelmanri's Arch., 1900, 433. 

6 Czerny and Keller: loc. cit. 



AND INFANT FEEDING 21 

fat may normally be found in a stool. There is a comparatively 
large amount of fat present in the first days of life, and this amount 
gradually becomes less as the babies grow older, 1 decreasing from 
50% of the dried stools to between 14 and 25%. There is so 
much fat passed in the stools during the early weeks that it is 
practically impossible to ascertain by simple microscopic ex- 
amination whether there is an excess or not. In later infancy 
less fat is present and, therefore, microscopic examinations are 
of more value. In normal and in many pathologic conditions the 
greater part of the fat, 75% or more, is split by the digestive juices 
and bacteria into fatty acids and soaps. 

METABOLISM 

Methods. — Most of the earlier figures of the metabolism of fat 
were obtained by the Rosenfeld extraction method, 2 or one of its 
modifications. Later Kumagawa and Suto 3 criticised these meth- 
ods and devised a saponification method which goes under their 
name. These two methods are the ones most commonly used on 
the continent. The Folin-Wentworth method 4 (extraction) is 
now used in America almost to the exclusion of the other two 
methods. Gephart and Csonka 5 have recently shown the pres- 
ence of errors in all of the above methods and have described a 
method by which they have endeavored to overcome these errors. 
Up to date there are no metabolism figures in infancy which were 
obtained by this method. When the methods are studied, it be- 
comes obvious that figures obtained by one method cannot fairly 
be compared with those obtained by another method, because they 
probably do not represent the same things. It is obvious also 
that slight differences in figures are of no significance and that only 
the most striking differences are of practical importance. Un- 
fortunately, the clinical status of the infant is not sufficiently con- 
trolled and recorded in most instances and the possibilities of 
error, both from errors in chemical technique, and in clinical ob- 
servation, are numerous. Despite these facts, it seems wise to 
summarize what we think we know about the digestion and ab- 
sorption of fat in health and disease. 

Fat Excretion on Fat-free Food. — A careful analysis of the 
figures that are at present available shows that even when the 

1 Talbot, F. B. : Boston Med. and Surg. Jour., 1909, vol. clx, No. 1, 13. 

2 Rosenfeld: Centralb. f. inn. Med., 1900, xxi, 833. 

3 Kumagawa and Suto: Biochem. Zeitschr., 1908, viii, 212. 

4 Folin and Wentworth: Jour. Biol. Chem., June, 1909-10, vii, 421. 

5 Gephart and Csonka: Jour. Biol. Chem., Dec, 1914. 



22 DISEASES OF NUTRITION 

quantity of fat in the food is very minute, an ether soluble sub- 
stance, which is recorded by investigators as fat, is found in the 
stools. In most instances in infants the amount of this substance 
is smaller than the amount of fat in the food, and if it is fat it 
might very well originate in the food. 1 On the other hand, since 
fasting adults have had small quantities of fat in the stools, it is 
argued that this fat must come from the body. The amount of 
fat in question is so small that the discussion is of more theoretical 
than practical importance. 

Fat Absorption in Health. — It is generally agreed that the 
fat absorption of healthy infants is very high both in the breast- 
fed and in the artificially fed. UrTelmann 2 found that a breast-fed 
infant absorbed approximately 97.8% of the fat ingested. Shaw 
and Gilday 3 found the absorption 96%, while Nobecourt and 
Merklen 4 found the absorption of fat respectively 98.3, 99.7, 
98.27, 98.23, and 98.62% in five healthy breast-fed infants. 
Further figures are given by Czerny and Kellar. 5 

The absorption of fat in normal artificially-fed babies is also 
extraordinarily good and, according to Freund, it may remain ab- 
solutely normal even under abnormal conditions of nutrition. He 
records instances with "soap stools" in which the fat absorption 
reached as high as 97% of the intake (see Czerny and Kellar, 5 and 
Freund). 6 Freund gives 91.86% to 98.98% as the figures for the 
absorption of fat for healthy, breast-fed infants. The figures 
are somewhat lower in the babies he calls "apparently normal," 
but analyses of these figures show that these babies are consider- 
ably under the average weight for their age and can, therefore, 
not be considered "average normal." Nevertheless many of these 
infants show a very good absorption of fat. 

The significance of fatty acids and soaps is as yet unknown. 
Freund 7 has shown that an acid dyspeptic stool can be changed 
in many instances to a formed "soap stool" by a relative increase 
in the amount of casein, while an alkaline soap stool can be changed 
into an acid stool by a relative increase in the amount of carbohy- 
drates. Coincident with the change from an acid to an alkaline 
stool there is a change of the intestinal flora; the acid-forming 

1 See expts. of Aschenheim (Kumagawa and Suto method), Jahrb. 
f. Kinderh., 1913, lxxvii, 505. 

2 Uffelmann: quoted by Tobler and Bessau, loc. cit. 

3 Shaw and Gilday: Brit. Med. Jour., 1906, ii, 932. 

4 Nobecourt and Merklen: Rev. mens des Mai. de L'enfance, 1904, xxii, 337. 

5 Czerny and Kellar: loc. cit. 

6 Freund: Ergeb. d. inn. Med. u. Kinderh., 1909, iii, 158-159. 

7 Freund: loc. cit. 



AND INFANT FEEDING 



23 



bacteria which previously predominated are replaced by the putre- 
factive group of bacteria. When an alkaline stool is made acid 
the reverse takes place. Bahrdt 1 has recently shown that babies 
passing "soap stools" have diminished powers of absorption and 
that they lose more fat than was formerly taught. He found the 
absorption of fat (Kumagawa and Suto method) as follows : 

TABLE 9 



Name of baby 


Age, 
months 


Weight, 
gm. 


Fat ab- 
sorbed, 
per cent 


Character of 
stools 


Schroder, 7 days 

Schuler, 7 days 

Weiss, la, 5 days 

Weiss, lb 

Weiss II, 8 days 
(Breast and skim milk) 


9 
2 

Vio 

7io 
10 


7470 
3945 
3750 
3750 

3900 


82.4 
83.2 
81.9 
86.0 

93.0 


Soap stools 
Mostly soap stools 
Soap stools 
Soap stools 

Normal stools 



The fat absorption in these babies with soap stools is, therefore, 
considerably less than that of normal infants. There is, however, 
not such a loss of fat as in diarrhea. 

It is very difficult to determine in the cases that have been pre- 
viously investigated how much their powers of digestion had been 
injured by previous poor feeding or disease. Conclusions as to the 
effect of the food on sick babies, on this account, must be very 
conservative. There seems to be little doubt, however, that in- 
creased peristalsis results in an increased loss of fat in the stools. 
Certain phases of this question will be considered in more detail 
later. Increased loss of fat in the stools may occur in any diarrhea, 
whether it be due for example, to an acute infection, or to chilling, 
or to an excess of sugar in the food. Birk's observations on Groeger 
III, during a period in which the temperature was elevated and he 
was passing frequent thin stools, showed an absorption of only 79%. 
Courtney 2 says that the lowest absorption in her cases, Janes 
52.3% and Stoker 34.2%, was the result of increased peristalsis and 
diarrhea. Usuki 3 found that when large amounts of malt extract 
were added to the food of an infant with alkaline stools the loss of 
fat in the stools increased from 10% to 15%. The same results 
were recorded for lactose by Talbot and Hill, 4 who found in their 

1 Bahrdt, H.: Jahrb. f. Kinderh., 1910, lxxi, 249. 

2 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

3 Usuki: Jahrb. f. Kinderh., 1910, lxxii, 18. 

4 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 



24 DISEASES OF NUTRITION 

case that the absorption of fat while the digestion was good was 
90% and that during a " sugar diarrhea" it dropped to 75%. 

The percentage of fat in the dried stool is higher in paraenteral 
febrile infections than in health. Uffelmann x found, for example, 
that in an eight months' old infant with acute bronchitis and fever 
the fat excretion in the stools was as follows : 

TABLE 10 

Fat 

4th day 40. 7% of dried stool 

7th day 37.8% of dried stool 

9th day 25.0% of dried stool 

13th day 15.2% of dried stool 

Fat Diarrhea. — Demme 2 and Biedert 3 described a condi- 
tion which they called a fat diarrhea which was characterized by 
frequent, acid, diarrheal stools. Tobler thinks that, on account 
of their acidity, these stools are not characteristic of a primary 
fat indigestion, but that they may be secondary to some other 
form of indigestion which causes rapid peristalsis. He cites, as 
evidence in favor of this point of view, the fact that such a diarrhea 
will stop when the food is changed to "Eiweissmilch," even though 
the percentage of fat remains the same. It is a fact, nevertheless, 
that in certain instances, in which very large amounts of fat have 
been fed to young infants, they have passed three or four stools 
daily of the yellow color of Indian meal and the consistency of 
mush. Careful inspection of such stools shows drops of oil on the 
surface of and intermixed with the stool, while the microscope 
shows that the stool is composed almost entirely of fat. When 
the amount of fat is reduced in these cases without any other 
change in the food, the digestion becomes normal. Such cases are 
true fat diarrheas. 

Whether the fat in the stool is in the form of fatty acids or soaps 
depends chiefly upon the reaction of the stool, which in its turn 
depends upon the relation of the food components to each other. 
Talbot 4 has shown that "soft curds" or fatty curds, when al- 
kaline to litmus paper, are composed principally of soaps and, 
when acid to litmus paper, principally of fatty acids. . 

The presence of a large amount of soaps presumably affects the 
absorption of the various salts. The technical difficulties in deter- 

1 Uffelmann: quoted by Tobler and Bessau, lot. cit. 

2 Demme: Jahrb. tiber die Thatigkeit des Jennerschen Kinderspitals in 
Berlin, 1874 and 1877; quoted by Hecht, Die Faeces des Sauglings, etc., p. 128. 

3 Biedert: Jahrb. f. Kinderh., 1879, xiv, 336; ibid., 1888, xxviii, 21. 

4 Talbot: Boston Med. and Surg. Jour., 1909, clx, 13. 



AND INFANT FEEDING 25 

mining the amount of calcium and other salts in the stools, make 
nearly all the figures very unreliable. 1 The usual conclusions 
from metabolism experiments are that in the normal infant, with 
a normal fat absorption, a high fat intake does not change the 
mineral composition of the stools, while in chronic malnutrition 
the output of salts in the feces is considerably raised by increasing 
the fat in the diet. 2 

Olive oil is considered by some authors to have a beneficial ac- 
tion on the absorption of fat. The metabolism experiments of 
Courtney 3 and Freund 4 apparently bear out this belief. 

Infantile Atrophy. — " Alimentary decomposition" of Finkel- 
stein — " Marasmus"). When the literature of the metabolism of 
u infantile atrophy" is studied the first questions which arise in 
the student's mind are what is the clinical picture of "infantile 
atrophy," and are all the cases reported under that name suffering 
from the same disease. The summaries of the clinical histories 
are so meagre that it is impossible to draw any definite conclusions 
from them and the statement of the investigator as to the clinical 
status of the given infant has to be accepted. This state of affairs 
is, of course, unfortunate, but with the present disagreement 
among authorities as to what the disease really is, it cannot be 
remedied. With modern improvements in the methods of diag- 
nosis it is possible to separate out chronic tuberculosis and heredi- 
tary syphilis as definite clinical entities. Prematurity should 
also be set aside by itself. This leaves, to be classed as "infantile 
atrophy," those cases which correspond to Holt's 5 definition, 
that "infantile atrophy is the extreme form of malnutrition seen in 
infancy, occurring so far as is known, without constitutional or 
local organic disease. It is a vice of nutrition only." There must 
be many stages of the disease if there is such a clinical entity. 
These facts must be borne in mind in considering the subsequent 
remarks. 

The fat content of the body of an atrophic infant as compared 
with the normal is very much diminished. Ohlrnuller 6 found that 
the body of an atrophic infant contained only 3% fat as com- 
pared to 21% in a normal infant. Steinitz 7 analyzed the bodies 

1 According to Prof. Folin only those figures of the calcium metabolism 
obtained by McCrudden's methods are of any value. 

2 Freund: Ergeb. d. inn. Med. u. Kinderh., 1909, iii, 139. 

3 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

4 Freund: Biochem. Zeitschr., 1909, xvi, 453. 

5 Holt: Dis. of Infancy and Childhood, N. Y. and London, 1911, p. 227. 
8 Ohlmiiller: Zeitschr. f . Biol. 1882, xviii, 78. 

7 Steinitz: Jahrb. f. Kinderh., 1904, lix, 447. 



26 DISEASES OF NUTRITION 

of three atrophic infants, weighing 3190, 2625 and 1960 grams, and 
found that the total amount of fat was respectively 63.6, 37.9 and 
35.9 grams, or from 1.45 to 1.99% of the total mass, as compared 
with from 12.3% to 13.1% in the normal. 

A fatty liver is occasionally found at post mortem examination, 
but, according to Holt, — "This lesion is not more frequent in this 
condition than in infants dying of other diseases." Hayaslei * 
recently showed that in five out of eight cases of " infantile 
atrophy" the liver contained neither fat nor lipoid substances. In 
two cases the livers were fatty. 

According to many authors 2 the digestive ferments are more 
or less diminished and weakened in infantile atrophy. This is 
especially true of the fat-splitting ferment. Hecht believes that 
there is a connection between the severity of the disturbance and 
the diminution in the amount of steapsin. Wentworth 3 found 
that secretin was either diminished or absent in these cases. 

The metabolism of fat varies. Freund 4 found that two atrophic 
infants with " milchnahrschaden " (soft curds) absorbed respec- 
tively 90% and 97% of the fat, except in one instance when one 
absorbed only 81.8%. Bahrdt, 5 on the other hand, found an 
absorption of only 81.9, 82.4, 83.2, 86.0 and 93%. 

L. F. Meyer 6 studied " infantile atrophy" in different stages 
and with different foods. He found in baby Kajitzki in periods 
I and II, in which whole milk, diluted one-half, was given, that 
the absorption of fat was respectively 74.2% and 24.9%. In the 
first period there was a slight gain in weight, and in the second 
period a marked loss in weight, with a corresponding loss of fat 
in the stool. In periods III, IV, and V, the absorption of fat was 
respectively 51.0, 68.3, and 78.6%, and during the last period 
there was a gain in weight. Baby Bentler did not show the same 
loss of fat, but there was a greater retention of fat when human 
milk was given than when cow's milk was given. 

Fife and Veeder 7 studied two cases which they considered to 
be "infantile atrophy" and found that the fat absorption (Brugsch 
method for fat) was less than in normal infants. Curiously enough, 
the per cent, of fat absorbed was larger when large amounts of 
fat were given than when small amounts were given. They did 

1 Hayaslei: Monatschr. f. Kinderh., 1913, xii, 221. 

2 Tobler and Bessau: loc. cit. 130. 

3 Wentworth: Jour. Am. Med. Assoc, 1907, xlix, 204. 

4 Freund: Biochem. Zeitschr., 1909, xvi, 453. 

5 Bahrdt: quoted by Tobler and Bessau, loc. cit. 

6 Meyer, L. F.: Jahrb. f. Kinderh., 1910, lxxi, 379. 

7 Fife and Veeder: Am. Jour. Dis. Children, 1911, ii, 19. 



AND INFANT FEEDING 27 

not find that the carbohydrates in the food had any influence on 
the fat absorption, but their evidence in this respect is incomplete. 

Wentworth * studied the fat metabolism (Folin-Wentworth 
method), of an atrophic infant and found that its tolerance for the 
fat in human milk was much greater than for that of cow's milk. 
His results were confirmed in the case of Kajitzki. 2 He was un- 
able to determine whether this difference in the absorption of the 
two kinds of fat was due to a difference in the fats themselves or 
to some other ingredient in the milk. 

Hecht 3 and Reuss 4 have reported cases of congenital oblitera- 
tion of the bile duct with normal pancreas, in which only one-half 
of the fat was split. In Niemann's case 5 of an infant with ad- 
vanced biliary cirrhosis and congenital absence of the bile ducts, 
the nitrogen absorption was from 80% to 93% and the fat absorp- 
tion from 28% to 39%. In Koplik and Crohn's case 6 the nitrogen 
absorption was 86.2% and the fat absorption 48.4%. Very much 
less than the normal amount of fat was split. Similar types of 
stools with large amounts of unsaponified fat have been observed 
by us clinically. 7 These figures show that in the infant as well as 
in the adult, bile is necessary for the normal splitting and absorp- 
tion of fat. 

Tubercular peritonitis in babies is primarily a disease of the 
lymphatic system and when the mesenteric glands become caseous 
they form a dam beyond which the fat cannot pass. It has been 
shown earlier that most of the fat is normally carried by the lym- 
phatics to the blood stream. If this road is blocked with tuber- 
culous tissue, it is reasonable that some of the fat should be lost 
from the body. Talbot 8 studied cases with tuberculosis of the 
mesenteric glands and found that in all cases in which a large 
proportion of these glands were involved there was a loss of fat 
through the intestines. Hecht 9 believes that 8% of the fat in 
the stool should be split, and considers that great divergence from 

1 Wentworth: Boston Med. and Surg. Jour., 1910, clxii, 869, and Archives 
Int. Med., 1910, vi, 420. 

2 Meyer, L. F.: loc. cit. 

3 Hecht: "Die Faeces des Sauglings und des Kindes," Berlin- Wien, 1910, 
128. 

4 Reuss: Case of Obliterated Bile Duct (congenital) Reported in Discus- 
sion,— Jahrb. f . Kinderh., Dec, 1908, 729. 

5 Niemann: Zeitschr. f. Kinderh., 1912, iv, 152. 

6 Koplik and Crohn: Am. Jour. Dis. Children, 1913, v. 36. 

7 Morse, J. L.: Boston Med. and Surg. Jour., 1910, clxii, 238. 

8 Talbot : Am. Jour. Dis. Children, 1912, iv, 49. (See literature.) 

9 Hecht: loc. cit. 



28 DISEASES OF NUTRITION 

this amount means either trouble with the bile or pancreatic juice. 
He reports the case of a seven months, premature baby which was 
able to split only 53% of the fat, and considers this to be due to 
weak action of the pancreatic fat-splitting enzyme, which pre- 
sumably is not completely developed. Finizio 1 explains a large 
amount of fat in the stool of an eleven months old baby ill with 
mumps by probable trouble in the pancreas. In this case 75% 
of the dried stool was fat, and of this only 7% was soaps, while 
11% was fatty acid and 82% neutral fat. 

Czerny 2 believes that babies with an exudative diathesis can 
be harmed by fat. He finds that an increase in the amount of fat 
in the food will bring out eruptions on the skin. Steinitz and 
Weigert 3 have apparently proved the correctness of this assump- 
tion by a metabolism experiment. 

Towle and Talbot 4 studied the digestion of infants ill with ec- 
zema and found that in a large number of cases the severity of the 
skin eruption bore a direct relation to the fat in the food. This was 
by no means the case in all instances, but there was a sufficient 
number to substantiate Czerny's findings. 

There is no doubt that large amounts of fat can do a great deal 
of harm to most babies. Such babies come under two classes, — 
those which have a normal digestion and are unable to digest ex- 
cessive amounts of fat, and those which have diminished powers of 
digestion and are unable to digest normal amounts of fat. So 
much attention has been paid to the few babies that are unable to 
digest fat that we are apt to forget that most babies can digest fat 
within reasonable limits. L. F. Meyer 5 has shown in Finkel- 
stein's clinic that when fat is increased in the food of normal 
healthy babies there is no loss of fat or salts from the body. This 
dispels, in a very convincing way, the false impression that normal 
babies are unable to digest fat. Howland has shown in a recent 
investigation (not yet published) that a baby can be fed on large 
quantities of fat without symptoms of indigestion and without 
acidosis. 

1 Finizio: Pediat. Sept., 1909, 674; Rev. in Archiv. f. Kinderh., 1910, liv. 461. 

2 Czerny: Part I, Monatschr. f. Kinderh., 1906, iv, 1; ibid., Part II, 1908, vi, 
l;ibid., Part 3, 1909, vii, 1. 

3 Steinitz and Weigert: Monatschr. f . Kinderh., 1910, ix, 385. 

4 Towle and Talbot: Am. Jour. Dis. Children, 1912, iv, 219. 

5 Meyer, L. F.: Jahrb. f. Kinderh., April, 1910, 379. 



AND INFANT FEEDING 29 



CHAPTER III 

THE DIGESTION AND METABOLISM OF CARBO- 
HYDRATES 

FERMENTS 

Saliva. — Zweifel * found diastase in the parotid gland of the 
newly-born, but was unable to find it in the submaxillary. Ibra- 
him, 2 after prolonged investigations, found it in both the parotid 
and submaxillary glands, its action being stronger in the former 
than in the latter. Diastase was found much earlier in fetal life 
in the parotid than in the submaxillary, traces being found in 
the former at the fourth and in the latter at the sixth month of 
fetal life. The diastase of the parotid is the earliest digestive fer- 
ment found in the embyro. 

A diastatic ferment can always be found in the saliva of healthy 
infants. 3 The diastatic action of saliva may continue in the 
stomach as long as two hours after feeding. 4 

Stomach. — Ibrahim 5 is the only worker who has examined the 
gastric mucous membrane of the newly-born for the carbohydrate 
splitting ferments, and he has been unable to find either lactase, 
maltase or invertin. 

Pancreas. — Moro 6 was able to demonstrate the presence of an 
amylolytic ferment in the pancreas of newly-born babies when the 
pancreas was thoroughly extracted, and thus disproved the earlier 
work of Zwiefel and Korowin. Ibrahim 7 never failed to get the 
ferment in a six months' fetus when he tested the action of the 
ferment on starch meal. He was, however, unable to find it when 
he tested soluble (i. e., cooked) starch. 

1 Zweifel: Untersuchungen fiber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 

2 Ibrahim: Verhandl. d. Gesell. fur Kinderh., Koln, 1908, p. 21. 
3 Schiffer: Berl. klin. Wochenschr., 1872, ix, 353; Korowin: Jahrb. f. 

Kinderh., 1875, viii, 381; Zweifel: loc. cit.; Schlossmann: Jahrb. f. Kinderh., 
1898, xlvii, 116; Montagne: Dissertation, Leyden, 1889, quoted in Czerny and 
Keller,— "Des Kindes Ernahrung," etc.; Schilling: Jahrb. f. Kinderh., 1903, 
lviii, 518. 

4 Shaw: Albany Med. Ann., 1904, xxv, 148. 

5 Ibrahim: loc. cit. 

6 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

7 Ibrahim: loc. cit. 



30 DISEASES OF NUTRITION 

Ibrahim was unable to demonstrate invertin and lactase in the 
pancreas of newly-born or older babies, but he was usually able to 
demonstrate maltase in the newly-born and always in older chil- 
dren. Maltase may also be found in the blood. 

Small Intestine. — The mucous membrane of the small intes- 
tine contains amylolytic ferments. 

Lactase, the ferment which splits milk sugar, has been repeatedly 
found in the mucous membrane of the small intestine. 1 Ibrahim 
always found it in the small intestine and meconium of newly-born 
babies, but was unable to find it in premature infants. He says, 
however, that his method of determining lactase is not capable of 
demonstrating small amounts. Lactase is more abundant in young 
animals than in the adult. 

Pautz and Vogel found maltase, the ferment which splits malt 
sugar, in the small intestine of infants. 

Invertin, the ferment which splits cane sugar, was found in the 
secretions of the small intestine of the newly-born by Miura 2 and 
Ibrahim was always able to demonstrate its presence both in the 
intestinal mucous membrane and in the intestinal contents of all 
fetuses. 

Large intestine. — It is difficult to wash the large intestine free 
from meconium, and the results of the examinations of its mucous 
membrane are variable, as the tables of Miura, Pautz and Vogel 
show. It is, therefore, impossible to say whether it contains fer- 
ments or not. 

Stools. — Pottevin 3 found an amylolytic ferment in the me- 
conium. Kerley, Mason and Craig 4 were able to demonstrate the 
presence of a strong amylolytic ferment in the stools of very young 
babies, the possibility of the bacterial fermentation of starch being 
excluded. There is a larger amount of diastase in the stools of 
breast-fed babies than in those of the bottle-fed, which Hecht 5 
believes to be due to the fact that the intestinal contents of the 
breast-fed baby pass more quickly through the intestinal canal 
than do those of the bottle-fed baby. The power of digesting 
starch, while occasionally absent is, therefore, almost always 
present both in the fetus and in the newly-born. Hess 6 always 
found it present during the first week of life, the amount of the 

1 Pautz and Vogel: Zeitschr. f. Biol., 1895, xxxii, 304; Weinland: ibid., 1899, 
xxxviii, 16; Orban: Prag. med. Wochenschr., 1899, xxiv, 427. 

2 Miura: Zeitschr. f. Biol., 1895, xxxii, 266. 

3 Pottevin: Compt. rend, de la Soc. biol, 1900, lii, 589. 

4 Kerley, Mason and Craig: Arch. Pediat., 1906, xxiii, 489. 

5 Hecht: "Die Faeces des Sauglings und des Kindes," Berlin, 1910. 

6 Hess: Am. Jour. Dis. Children, 1912, iv, 205. 



AND INFANT FEEDING 



31 



ferment increasing with the age of the infant. Young babies are, 
nevertheless, able to adapt themselves to a food rich in carbo- 
hydrates. There is according to Moro, 1 a rapid increase in the 
power of digesting starch during the first week of life. The baby, 
therefore, has a power of digesting starch at birth which gradually 
increases in strength as the baby grows older. According to 
Finizio 2 it is twice as strong at eight months as it is at birth, 
while at twelve months it is almost as strong as at three years. 

The question whether the carbohydrate-splitting ferments are 
affected by disease has been answered only in part. Orban 3 found 
by animal experimentation that an injured intestinal mucous 
membrane contained no lactase, and that the stools of babies ill 
with enteritis contained no lactase. Langstein and Steinitz 4 on 
the other hand, always found lactase in the stools of babies ill with 
enteritis, whether mild or severe, acute or chronic. Nothmann 5 
was unable to demonstrate lactase in the stools of seven premature 
babies on the first day post partum, but found it always after milk 
had been fed. 

FORMS OF CARBOHYDRATES 

The forms of carbohydrates commonly used in infant feeding 
may be divided into the groups given in the following table (taken 
from Reuss 6 ) . 

TABLE 11 



Milk sugar group 



Cane sugar group 



Malt sugar group 



Lactose (milk sugar) 



Dextrose + Galactose 



Saccharose (cane sugar) 

I 

Dextrose + Levulose 



Starch (Amylum) 

I 

Dextrin (Amylo-dextrin) 

,1 

Erythro & Achro-dextrin 

I 

Maltose (malt sugar) 



Dextrose + Dextrose 



1 Moro: Jahrb. f. Kinderh., 1898, xlvii, 342. 

2 Finizio: Rev. d. Hyg. et Med. Inf., 1909, viii, 224. 

3 Orban: Prag. med. Wochenschr., 1899, xxiv, 427. 

4 Langstein and Steinitz : Hoffmeister's Beitrage, 1909, vii, 575. 

5 Nothmann: Monatsschr. f. Kinderh., 1909-10, viii, 377. 

6 Reuss: Wien. med. Wochenschr., 1910, lx, Nos. 28, 29, 30. 



32 DISEASES OF NUTRITION 

DIGESTION OF CARBOHYDRATES 

The carbohydrates are broken down during digestion into the 
simplest forms of sugar, the monosaccharides, by the various 
ferments described above. According to Rohmann l a consider- 
able amount of the di-saccharides may pass into the intestinal 
mucous membrane and there be split into mono-saccharides. The 
mono-saccharides are carried from the portal vein to the liver, 
where they are transformed into glycogen, the only difference being 
that dextrose is more easily converted than levulose or galactose. 2 
The pancreas has some influence on this process because extirpation 
of the pancreas in dogs results in sugar in the urine and interferes 
with the formation of glycogen in the liver. The liver actually 
has the property of forming glycogen from sugar. 3 

The purpose of the splitting of the poly- and di-saccharides into 
mono-saccharides is to prepare them for use inside the body, be- 
cause the unsplit carbohydrates are not burned up in the body, but 
are excreted in the urine. The transformation of sugar into 
glycogen which is deposited in the liver and muscles, is of great 
importance because this glycogen can be converted again into sugar 
according to the needs of the body. 

There is normally about 1-10% of dextrose in the blood. The 
slightest disturbance of the regulating apparatus will cause a 
hyperglycemia which results in glycosuria. A deficit of sugar 
in the blood is made up from the glycogen deposits. 4 The mono- 
saccharides are absorbed more quickly than the di-saccharides. 5 

A large part of the digestion and absorption of the carbohydrates 
takes place in the upper part of the small intestine. 6 Splitting and 
absorption may also take place in the large intestine. 7 

The bacteria of the stomach and intestines attack not only 
cellulose but other carbohydrates as well. The decomposition of 
the carbohydrates by means of bacteria, in general, is not very 
extensive and depends very much on the external conditions. The 
products formed by their action are chiefly lactic acid, acetic acid, 

1 Rohmann: Pfluger's Arch. 1903, xcv, 533. 

2 Alderhalden: Textbook of Physiological Chemistry, London, 1908. 

3 Grube: Pfluger's Arch., 1905, cvii, 490. 

4 Langstein-Meyer: Sauglings Ernahrung und SauglingsstoflNvechsel, Wies- 
baden, 1910. 

5 Hedon: Compt. rend, de la Soc. de Biol., 1900, 29; Nagano: Pfluger's 
Archiv., 1902, xc, 389; Rohmann: Chem. Bei., 1895, xxviii, 2506. 

6 London and Polowzowa: Zeitschr. f. physiol. Chem., 1906, xlix, 328. 

7 Reach: Arch. f. exp. Path u. Pharm., 1902, xlvii, 230; Schonborn: Diss. 
Wurzburg, 1897; Pehu and Porcher: Rev. d'Hyg. et de Med. Inf., 1910, ix, 1. 



AND INFANT FEEDING 33 

formic acid, butyric acid and alcohol with, in addition, the evolu- 
tion of carbon dioxide, hydrogen, and methane. 1 In abnormal 
conditions the bacteria probably play a much more important part 
in the breaking down of carbohydrates. 

Little or no sugar can be found in the stools under normal condi- 
tions, but when the food passes quickly through the intestinal 
canal, as it does when the peristalsis is increased as the result of 
disease or indigestion, sugar may be found in the stools (Hecht). 
Usually, only the products of the decomposition of sugar can be 
isolated. 

Hedenius 2 fed babies on milk mixed with wheat flour, oat gruel 
or Keller's malt extract and measured the amount of carbohydrate 
ingested, the amount found in the stools, and the acidity of the 
stools. He found less carbohydrate in the stools when simple 
cereals were used than when the more complicated mixtures were 
given. He also found that the more carbohydrate there was in the 
stool, the greater was its acidity. He never found more than three 
per cent of the ingested carbohydrate in the stools. 

Raczynski 3 has shown that in babies sick with what he calls 
" dyspepsia intestinalis acida lactorum," the acidity of the intes- 
tinal contents is increased and the utilization of fat diminished. 

Talbot and Hill 4 found in their case (J. P.), that an increasing 
amount of lactose in the food did not appreciably influence the 
titratable acidity of the stool until a diarrhea commenced. The 
acidity then increased five hundred per cent and lactic, acetic, 
succinic and butyric acids were found to be present. This fact 
seemed to indicate that the acid-forming bacteria played an im- 
portant part in the breaking down of the sugar. 

Keller 5 has shown that carbohydrates make the digestion of 
protein more complete. Talbot and Hill 6 have recently confirmed 
these findings. A possible explanation of the protein-sparing ac- 
tion of carbohydrates may be found in the work of Kendall and 
Farmer 7 on the metabolism of bacteria. They found that in the 
test-tube, when sugar was* present in the food, less ammonia 
nitrogen was formed than when sugar was absent. If the results 
obtained in the test-tube are applicable to the intestinal canal, the 

1 Tappeiner, H.:Zeitschr. f. Biol., 1883, xix, 228. 

2 Hedenius: Ueber das Schicksal der Kohlehydrate im Sauglingsdarm. 

3 Raczynski: Wien. klin. Wochenschr, 1903, xvi, S42. 

4 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 

5 Keller: "Des Kindes Ernahrung," etc., — loc. cit. 

6 Talbot and Hill: Am. Jour. Dis. Children, 1914; viii, 218. 

7 Kendall and Farmer: Jour. Biol. Chem., 1912, xii, 13; 1912, Nos. 1, 2 and 3; 
1912-13, xiii, 63. 



34 DISEASES OF NUTRITION 

reason that more nitrogen is retained in the body when sugar is 
present is not because the sugar makes the nitrogen more easily 
absorbable, but because the intestinal bacteria use the sugar in 
preference to the protein and form less nitrogen to be carried away 
in the stools. In other words, the bacteria leave a larger amount of 
nitrogen for absorption than when they grow on a sugar-free 
protein. 

Albertoni * and Hedon 2 found that sugars have a purgative 
action when they are given in large enough amounts. This action 
is more marked when they are taken in concentrated solution. 
All sugars have this action, the difference between them being 
only in degree. They found that glucose and cane sugar are much 
more quickly absorbed than lactose, and that glucose has less of a 
purgative action than the cane sugar. According to the extensive 
experiments of Rohmann and Nagano 3 saccharose is absorbed 
more quickly than maltose. 

METABOLISM OF CARBOHYDRATES 

Numerous observations 4 have shown that when milk sugar 
is injected directly into the circulation it may be completely re- 
covered in the urine. Grosz 5 was never able to detect milk sugar 
in the urine of healthy babies, but found it in the urine of those 
suffering with gastrointestinal disease, in which there was pre- 
sumably an absence of lactase in the intestine. Langstein and 
Steinitz 6 repeated Grosz's experiments and in certain instances 
found lactase in the stools at the same time that sugar was being 
excreted in the urine. This sugar was, moreover, not always lactose, 
but sometimes galactose, one of the products of the splitting of 
lactose. They tried to explain this as follows: — That some of the 
sugar passes through areas of the intestinal wall made abnormal 
by functional or anatomical lesions before it is completely broken 
up and it is excreted in the urine as an intermediary product of 
metabolism. 

Mendel and Keliner 7 have shown that when cane sugar is 
introduced subcutaneously into dogs or cats in doses of one to two 

1 Albertoni: Arch. ital. de Biol., xv, xviii, xxx, xxxv, xxxviii, xl. 

2 Hedon: Compt. rend, de la Soc. de Biol., 1899, 884; ibid., 1900, 29 and 87. 

3 Rohmann and Nagano: quoted by Hammarsten and Mandel, "Textbook 
of Physiological Chemistry, New York, 1912, 509. 

4 Voit: Deutsch. Arch, fur klin. Med., 1897, lviii, 523. 

5 Grosz: Jahrb. f. Kinderh., 1892, xxxiv, 83. 

6 Langstein and Steinitz : Moffmeister's Beitrage, 1906, vii, 575. 

7 Mendel and Keliner: Am. Jour. Physiol., 1910, xxvi, 396. 



AND INFANT FEEDING 35 

grams per kilogram of body weight it is not completely recovered 
in the urine. The quantity excreted amounts as a rule to more 
than 65% of that introduced. The excretion begins within a few 
minutes and is usually completed within thirty-six hours. Fisher 
and Moore * draw attention to the possibility that the sugar thus 
introduced may be excreted through the walls of the alimentary 
tract and there be digested. These views are supported by Jappelli 
and D'Errico, 2 who conclude from their experiments on dogs that 
when cane sugar is introduced directly into the circulation the 
quantity eliminated in the urine is never equivalent to the amount 
injected. This causes both glycosuria and saccharosuria, the 
former disappearing first. The blood has no power of converting 
cane sugar. According to these writers cane sugar introduced 
intravenously is eliminated into the alimentary tract through the 
gastric mucosa, the salivary glands and, to an insignificant degree, 
through the bile. The subsequent fate of this component is obvious. 
In the year 1906, Finkelstein published the first of a series of 
papers 3 which have caused much discussion as to the etiology of 
the digestive disturbances of infancy. In the first place he opposed 
Czerny's teachings as to the harmfulness of fat in infant feeding. 
He taught that bacteria played no part in the etiology of the 
digestive disturbances of infancy and that the sugars produced 
symptoms of intoxication. He also undertook to prove that the 
albumens were quite harmless. He considered that the most 
acute form of disease of the digestive tract, that accompanied by 
stupor, fever, and sugar in the urine, was the result of an intoxica- 
tion caused by sugar. He blamed lactose for the poisoning of the 
system, and claimed that instantaneous benefit and cure resulted 
from the complete withdrawal of sugar. Schaps 4 and Leopold and 
Reuss 5 also thought that lactose and other sugars were pyrogenic. 
In 1909, Finkelstein said, — "It is possible, with the certainty of 
an experiment, by giving a dose of sugar (for example 100 grams 
of a 12.5% lactose solution), to an infant with bowel trouble to 

1 Fisher and Moore: Am. Jour. Physiol., 1907, xix, 314. 

2 Jappelli: Ref. Maly's Jahresbericht fur Tierchemie, 1905, xxxv, 79. 

3 Finkelstein: Verhandl. Gesellsch. f. Kinderh. (Stuttgart), 1906, xxiii, 117; 
Jahrb. f. Kinderh., 1907, lxv, 1 and 263; Jahrb. f. Kinderh., 1908, lxviii, 521; 
Deutsch. med. Wochenschr., 1909, xxxv, 191; Finkelstein and Meyer: Jahrb. f. 
Kinderh., 1910, lxxi, 525 and Berliner klin. Woch., 1910, xlvii, 1165. For litera- 
ture and an excellent discussion of the subject, see chapter on "Sugar in the 
Young" in Allen, — "Glycosuria and Diabetes," Harv. Univ. Press, 1913. 

4 Schaps: Verhandl. Gesellsch. f. Kinderh., 1906, xxiii, 153; Berliner klin. 
Wochenschr., 1907, xliv, 597. 

5 Leopold and Reuss: Monatschr. f. Kinderh., 1909-10, viii, 1 and 453. 



36 DISEASES OF NUTRITION 

force up the previously afebrile temperature into fever, practically 
with the same certainty as if one should give it a dose of tubercu- 
lin." Later, he found that fever also resulted when physiological 
salt solution was given by mouth. His "eiweissmilch" was pre- 
pared to cure sugar intoxications. He apparently overlooked the 
fact that it contained 1J^% or more of the lactose which he con- 
sidered so poisonous in this condition. As his theories developed, 
he decided that the sugar intoxication was not due to a sugar 
injury alone, but to the actions of salts, especially the chlorine-ion 
combination with sodium. Friberger, 1 Schloss, 2 Cobliner, 3 and 
Nothmann, 4 confirmed Meyer's statements concerning the pyrexial 
effects of sodium-halogen compounds, while Rosenthal 5 found that 
in animals neither salt nor sugar had any specific pyrogenic action. 

In 1910 Finkelstein and Meyer ascribed intestinal irritation to 
abnormal fermentations. They stated that casein was never 
harmful and that it prevented or diminished acid fermentation. 
They stated, on the other hand, that, as Czerny pointed out, fat 
was more dangerous, but claimed that it was only harmful in a 
bowel irritated by carbohydrate fermentation. They admitted, at 
this time, that human milk was the best food to give in these condi- 
tions, thus abandoning their earlier contention that lactose (which 
is present in large amounts in human milk) is poisonous. 

Helmholz 6 found that 5% solutions of sodium chloride, bromide, 
and iodide injected into rabbits subcutaneously in quantities of 
from ten to twenty-five cubic centimeters caused no rise of temper- 
ature in the great majority of experiments. Sodium chloride pro- 
duced a slight rise in temperature when given intravenously in high 
concentration. A 1% solution of sodium chloride may, in excep- 
tional instances, produce a febrile rise in temperature when given by 
mouth. Schlutz 7 confirmed theso findings; he found that lactose 
alone possesses no distinct pyrogenic action, but that it may affect 
the temperature if it is given in combination with a sodium salt 
when the intestinal tract is diseased. 

Allen 8 studied the effects of sugars in young, nursing animals 
and found that in no instance were there any symptoms of the 
intoxicating action of sugar, even when the animals received so 

1 Friberger: Munch, med. Wochenschr., 1909, lvi, 1946. 

2 Schloss: Biochem. Zeitschr., 1909, xviii, 14. 

3 Cobliner: Zeitschr. f. Kinderh., ii, 429. 

4 Nothmann: Zeitschr. f . Kinderh., i, 73. 

6 Rosenthal: Jahrb. f. Kinderh., 1909, Ixx, 123. 

6 Helmholz: Arch, of Internal Medicine, 1911, vii, 468. 

7 Schlutz: Am. Jour. Dis. Children, 1912, iii, 95. 

8 Allen: "Glycosuria and Diabetes," Harvard Univ. Press, 1913. 



AND INFANT FEEDING 37 

much sugar by mouth that they had vomiting and diarrhea. He 
found, furthermore, that subcutaneous injections of glucose had a 
very beneficial action on animals, even when they had glycosuria 
and were doing badly. The evidence at hand is opposed to the be- 
lief that sugar has any specific intoxicating effect or acts as a food 
poison and is in favor of the theory * that it is a medium of growth 
for bacteria in which they can develop sufficiently to harm the body 
either by their own activity or by the products which result from 
their activity. 

The limits of assimilation of the different sugars vary and are 
given as follows : 

Grape sugar: In babies, about 5 grams per kilogram (Langstein 
and Meyer). 

Grape sugar: In one month baby, 8.6 grams per kilogram 
(Greenfield). 2 

Galactose : No accurate data. 

Levulose: (Lower for babies than adults), one gram per kilogram 
(Keller). 

Maltose: Over 7.7 grams per kilogram (Reuss). 

Lactose: From 3.1-3.6 grams per kilogram (Grosz). 

Cane sugar : Probably about the same as lactose (Reuss) . 

The main facts w T hich are apparently true about the metabolism 
of carbohydrates in infancy are: — carbohydrates are absorbed up 
to a certain point, lactose being absorbed more slowly than the 
other di-saccharides. Up to a certain point lactose and maltose 
increase the retention of nitrogen, but apparently have no in- 
fluence on the retention of ash or the absorption of fats. Beyond 
that point there is a marked increase in the acidity of the intestinal 
canal which results in increased peristalsis, and which washes the 
irritating food out of the bowels as quickly as possible. Large 
amounts of fat, protein and ash are carried out in the stools, 
resulting in a diminished absorption and retention of these food 
components. 

Starches act in the same manner as the other carbohydrates 
except that having a more complicated molecule, they go through 
one more step in the process of their conversion into a mono- 
saccharide. 

1 Escherich: Deutsche Klinik, 1902, vii, 126. 
* Greenfield: Jahrb. f . Kinderh., 1903, lviii, 666. 



38 DISEASES OF NUTRITION 



CHAPTER IV 
THE DIGESTION AND METABOLISM OF PROTEIN 

FERMENTS 

The saliva of man was shown to contain a proteolytic ferment 
by Ed. Mtiller, 1 but up to date such a ferment has not been found 
in infants. 

Pepsin was first demonstrated in the mucous membrane of 
the infant's stomach by Zweifel 2 and later Langendorff 3 ex- 
tracted it with HGL from the stomach of a fetus of four months, at 
which time there is microscopic evidence of glandular formation. 
The amount of pepsin increases with the age of the baby up to the 
third month, and from then on remains constant in amount; it is 
present in larger quantities in bottle-fed babies than in breast-fed 
babies. 4 Pechstein 5 examined the urines of babies at different 
ages and under different conditions and found that all babies 
excrete pepsin and rennin in their urine from the day of their 
birth onward. These ferments are present only in the form of 
their pro-ferments. They are found in minute quantities in the 
early days of fife and increase in amount up to the end of the 
first year, at which time there is about one twentieth as much as in 
the adult. The urine of the artificially-fed baby contains more 
than does that of the breast-fed baby. During an acute disturb- 
ance of digestion they are as abundant as in health, but during 
chronic diseases they seem to be slightly diminished in amount. 
When pepsin and rennin are fed to a baby, no traces are found in 
the urine, and there is no increase in the amount of rennin in the 
stool. The ferments must, therefore, have been destroyed in the 
upper intestine or neutralized in the blood stream. If the intestinal 
mucous membrane is damaged, the ferments appear in the urine. 

Rennin and hydrochloric acid are found in the first days of 

1 Ed. Miiller: Verhandl. d. Cong, fur inn. Med., 1908, 676. 

2 Zweifel: Untersuchungen iiber den Verdauungsapparat der Neugeborenen, 
Berlin, 1874. 

3 Langendorff: Arch, fur Anat. u. Physiol., 1879, 95. 

4 Rosenstern: Berl. klin. Wochenschr., 1908, 542. 

5 Pechstein: Zeitschr. f. Kinderh., 1911, i, 365. 



AND INFANT FEEDING 39 

life. 1 Rennin has been demonstrated in sterile meconium 2 and 
a rennin ferment which acts independently of the stomach and 
pancreas 3 has been found in the stool. 

Trypsin. — Zweifel demonstrated trypsin in the pancreatic 
extracts of new-born babies, and Langendorff found it at the 
beginning of the fifth month of fetal life. Ibrahim 4 showed that 
when absolutely fresh material was used only the pro-ferment 
trypsinogen is present in the pancreas of the fetus, but that small 
amounts of trypsin may be present in the pancreas of older chil- 
dren. This can be markedly increased by activating it with enter- 
okinase. The pro-ferments are apparently activated by bacteria, 
which are, of course, not present in the intestinal canal of the fetus. 
He was able to demonstrate trypsinogen in a six-months-old fetus. 

Trypsin is found in the feces in small amounts in health and in 
large amounts during diarrhea caused either by drugs or disease. 
Sterile meconium has the property of dissolving gelatine. 5 Hecht 6 
demonstrated trypsin in the stools of babies as early as the first day 
of life. 

Wienland 7 found anti-pepsin in the stomach and anti-trypsin 
in the intestinal mucous membranes; he believed that their func- 
tion was to prevent auto-digestion. Cohnheim 8 believes that anti- 
trypsin is identical with enterokinase and that in small amounts it 
activates trypsin, and in large amounts prevents its action. 

Enterokinase. — The ferment which activates trypsinogen was 
first found by Ibrahim, who extracted it from the intestinal 
mucous membrane of new-born babies, and from meconium. It is 
most active in the lower third of the intestine in the majority 
of instances; it may also be obtained from the mucous mem- 
brane of the large intestine. It apparently first appears in em- 
bryonic life at the same time that trypsin is found in the pancreas. 

Secretin, according to Baylies and Starling, 9 is necessary for 
the activation of the pancreas. It may be extracted from the 
intestinal mucous membrane; it is not destroyed by heat, and 
belongs to the group of hormones. When injected intravenously it 

1 Szydlowski: Jahrb. f. Kinderh., 1892, xxxiv, 411. 

2 Pottevin: Compt. rend, de la Soc. de Biol., 1900, lii, 589. 

3 Th. Pfeiffer: Zeitschr. f. Exp. Path. u. Therap., 1906, iii, 381. 

4 Ibrahim: Gesellschaft Deutscher Naturforscher und Artzte in Coin, 
1908. 

5 Pottevin: loc. eit. 

6 Hecht: Wien. klin. Wochenschr., 1908, xxi, 1550. 

7 Wienland: Zeitschr. f. Biol., 1903, xliv, pt. I. 

8 Cohnheim: NageFs Handbuch d. Physiol., 1907, ii, 597. 

9 Baylies and Starling: Jour. Physiol., 1902, xxviii, 325. 



40 DISEASES OF NUTRITION 

causes a flow of pancreatic juice in about one minute. Ibrahim and 
Gross * found it in babies who died at birth, but not in premature 
babies. Wentworth 2 found it absent or present only in small 
amounts in newly-born babies. He found definite but weak action 
in a premature baby which had lived three weeks. Older babies, 
which had died of other diseases than those of the digestive tract, 
all showed a definitely active secretin. Hallion and Lequeux 3 
found secretin in the upper part of the intestine of two newly-born 
babies, but were unable to find it in the lower part of the intestine. 
They obtained the same results in a five months' fetus. There is 
no record of secretin being found in the feces. 

Erepsin was first demonstrated in the intestinal mucuous 
membrane by Cohnheim. 4 It changes albumoses and peptones 
very rapidly into amino- and diamino-acids, so that the Biuret 
reaction disappears. It has no action upon the native albumens 
with the exception of casein. It is present in all babies, including 
premature infants. 5 

Lust 6 found an anti-proteolytic ferment in the blood of an 
infant fourteen days old, which had the same anti-tryptic power as 
that in the blood of an infant of one year. There is no increased 
formation of this ferment in digestive disorders, while in some cases 
of alimentary intoxication, in which there is loss of protein from the 
body, there is an increased amount of the anti-ferment. 

Mitra 7 was unable to find nuclease or connectivase which could 
digest muscle fibre and connective tissue in the stomach of an 
infant twelve months old, but found both ferments in a child of 
fifteen months. Rossi 8 measured the stimulating effect of saliva 
on the pepsin digestion by the Mett method. He found it greatest 
in the early stages of digestion but it became almost imperceptible 
at the end of four hours. Wakabayashi and Wohlgemuth 9 found 
that the large intestine contains erepsin, nuclease, hemolysin and a 
fibrin enzyme. 

The changes which protein undergoes during digestion may be 
briefly enumerated as follows: 

1 Ibrahim and Gross: Jahrb. f. Kinderh., 1908, lxviii, 232. 

2 Wentworth: Jour. Am. Med. Assoc, 1907, 119, 204. 

3 Hallion and Lequeux: Compt. Rend, de la Soc. de Biol., Paris, 1906, lxi, 33. 

4 Cohnheim: Zeitschr. f. Physiol. Chemie. Mitteilungen iiber das Erepsin, 
1902, xxxv, 134. Notiz iiber das Erepsin, 1906, xlvii, 286. 

5 Langstein: Jahrb. f. Kinderh., 1908, lxvii, 9. 

6 Lust: Miinchen Med. Wochenschr., lvi, 2047-2051. 

7 Mitra: Folia clinica, iii, 274. 

8 Rossi: Arch. Fisiol., viii, 484; from Zentralbl. Biochem. u. Biophys., ii, 436. 

9 Wakabayashi and Wohlgemuth: Internat. Beitr. Path. Therap., ii, 519. 



AND INFANT FEEDING 41 

When it is ingested it is split and hydrolyzed by the various 
ferments in a definite sequence. Pepsin reduces it into albumoses 
and peptones. Trypsin and erepsin then split these bodies further 
into amino acids, with an intermediary stage of polypeptides. The 
end products of protein digestion are amino acids and their combi- 
nations. 

Folin and Denis * and Van Slyke and Meyer 2 showed that the 
amino acids are absorbed as such from the alimentary tract. The 
evidence adduced by these observers that the amino acids reach the 
blood stream as amino acids and are carried to the tissues to be 
used in the formation of new tissue or to be disintegrated with the 
resultant production of the end product urea, has been strength- 
ened by the work of London. 3 During digestion the amount of 
amino-nitrogen increases not only in the portal blood but also in 
the peripheral circulation. 

CASEIN CURDS 

Twenty-eight years ago Biedert 4 published the first of a series 
of papers, in which he tried to show that many of the disturb- 
ances of digestion in infancy were due to difficulty in digesting 
casein. He believed that the bean-like masses which appeared 
in the stools of artificially-fed babies during disturbances of di- 
gestion were either casein or one of its derivatives. He found 
that their microscopic appearance was similar to that of coagulated 
casein and that they turned pink with Millon's reagent. Weg- 
scheider, 5 Uffelmann, 6 Escherisch, 7 and Fr. Miiller 8 were unable to 
confirm Biedert's assumption and concluded from their own 
experiments that the " so-called casein curds" were formed of 
calcium soaps, epithelium, bacteria, and intestinal secretions. It 
was shown, furthermore, that Biedert's methods of proving the 
presence of casein 9 were of no positive value since nucleo-protein 
and nucleo-albumen gave the same tests. 10 

1 Folin and Denis: Jour, of Biol. Chem., 1912, xi, 87 and subsequent papers. 

2 Van Slyke and Meyer: Jour. Biol. Chem., 1912, xii, 399. 

3 London: Zeitschr. f. Physiol. Chem., 1913, lxxxvii, 313. 

4 Biedert: Jahrb. f. Kinderh., 1888, xxviii, 21. 

5 Wegscheider: Ueber normale Verdauung bei Sauglingen. Innaug. Diss. 
Strassburg, 1875; cited by Blauberg: Experimentelle und kritische Studien 
iiber Sauglingsfeces bei naturliche u. kunstlicher Ernahrung, Berlin, 1897. 

6 Uffelmann: Deutsch. Arch. f. klin. Med., 1881, xxviii, 437. 

7 Escherisch: Jahrb. fur Kinderh., 1888, xxvii, 100. 

8 Fr. Miiller: Zeitschr. fiir Biol., 1884, xx, 327. 

9 Biedert: Arch. f. Gynak., 1907, lxxxi, 1. 

10 See also Southworth and Schloss: Arch. Pediatrics, 1909, xxvi, 241. 



42 



DISEASES OF NUTRITION 



Talbot 1 showed that there are two kinds of curds, one of which is 
large and tough and contains a high percentage of protein, and 
the other which is small and soft and contains a low percentage of 
nitrogen and a high percentage of fat. The former are tough, 
bean-like masses of varying size and shape, weighing from 34 to 
V/2 gm., the color varying from white to greenish-yellow according 
to how much they are stained by the bile and intestinal secretions. 
They may be easily separated from the fecal material in which they 
are imbedded and become extremely hard when treated with 10% 
formaline solution. These curds are the ones examined by Biedert. 
The small, soft curds are either flat, white flakes (which look like 
undigested particles of milk) or pinhead elevations, which are 
stained green or yellow by the intestinal secretions. They are 
always associated with more or less mucus and are composed al- 
most entirely of fat in the form of fatty acids or soaps. These 
curds are probably the ones examined by Biedert's opponents. 

Knopfelmacher 2 and Selter 3 examined the tough curds chem- 
ically and concluded that they were composed of casein. 

The chemical composition of casein curds is as follows: 



TABLE 12 







Curds 
















Neutral 


Fatty 


Soaps. 


Author 


Fat in food 


Nitro- 


Total 


fat. % 


acid.% 


%of 


% 


gen. % 


fat.% 


of dried 


of dried 


dried 






of dried 


of dried 


stool 


stool 


stool 






stool 


stool 








Talbot 4 


3.75 


7.2 


46.8 


36.4 


4.6 


5.8 




3.50 


9.8 


28. 


21.4 


1.2 


5.6 


Benjamin 5 . . . . 


"Eiweissmilch" 


10.4 


27. 








Courtney a . . . . 


2.3 

1.8 


10.6 
10.6 


22.3 
19.0 








Talbot 4 


"Fat free milk" 


12.0 


8.4 


2.2 


0.8 


5.4 



The foregoing table gives analyses of selected curds from three 
investigators and shows the general tendency for the amount of 
fat in the curd to increase with the amount of fat in the milk. 

1 Talbot: Boston Med. and Surg. Jour., 1908, clviii, 905; and ibid., Jan. 7, 
1909. 

2 Knopfelmacher: Wien. klin. Wochenschr., 1898, 1024; ibid., 1899, 1015; 
ibid., 1899, No. 52, 1038; and Jahrb. f. Kinderh., 1900, lii, 545. 

3 Selter: Verhandl. d. Gesellsch. f. Kinderh., Stuttgart, 1906, 177. 

4 Talbot: Boston Med. and Surg. Jour., 1908, clviii, 905. 

5 Benjamin: Zeitschr. f. Kinderh., 1914, x, 185. 

6 Courtney: Am. Jour. Dis. Children, 1912, iii, 1. 



AND INFANT FEEDING 43 

Conversely the amount of nitrogen diminishes as the fat increases. 
This seems to indicate that fat, the accidental component of the 
curd, dilutes the nitrogen. 

These experiments were not considered conclusive by most 
pediatricians, especially those of the schools of Czerny, Finkelstein 
and Heubner, while Biedert and many American schools thought 
that they were casein. Wernstedt 1 compared under the micro- 
scope and microchemically the tough curds found in the stool 
with those found in the stomach and concluded that they were 
casein. 

Recently, Talbot, Bauer, Uffenheimer and Takeno 2 working at 
approximately the same time with different methods, showed 
by the precipitine method, by anaphylaxis, and by complement 
fixation that the protein in tough curds was cow casein. None of 
these methods were sufficiently fine to tell whether some of the 
casein was changed into paracasein or not. 

When milk curdles in the infant's stomach it entangles a large 
proportion of the milk fat in its meshes and only such fat as lies 
near the surface of the curd can be reached by the digestive juices. 
The amount of fat in the curd depends upon the amount of fat in 
the milk. 3 Courtney 4 did not find any great variation in the 
percentage of fat in the curds examined by her. This is what would 
be expected, because there was no great variation in the percentage 
of fat in the food of the babies passing the curds. She went fur- 
ther, however, and examined the stool mass surrounding the curds 
and concluded that the casein curds are not pathognomonic of any 
pathological condition, and that the loss of food occasioned by their 
formation and the impairment of the general nutrition resulting 
from it is insignificant. Finally, that in attempting to correct the 
state of digestion one should be guided by the general rules of 
infant feeding, paying only secondary attention to the appearance 
or disappearance of curds from the stools. 

Howland 5 believes that the presence of casein curds in the stools 
is of "limited, if any, pathological importance, but rather depends 
on physical conditions in the gastrointestinal tract." Benjamin 6 
notes that casein curds appear in the stools of healthy as well as 

1 Wernstedt: Hygiea, 1907, No. 9, ref. Munchen Med. Wochenschr., 1907, 
2543. 

2 Talbot: Arch. Pediat., 1910, xxviii, 440; Uffenheimer and Takeno: Zeits. f. 
Kinderh., 1911, ii, 32; Bauer: Monatschr. f. Kinderh., 1911, x, 239. 

3 Talbot: loc. cit. 

4 Courtney: Am. Jour. Dis. Children, 1912, iii, 1. 

6 Howland: Am. Jour. Dis. Children, 1913, v. 390. 
8 Benjamin: Zeitschr. f. Kinderh., 1914, x, 185. 



44 DISEASES OF NUTRITION 

of dyspeptic infants and that there is less gain in weight while these 
curds are being passed than when they are absent. There is no 
question, however, that the casein curds are relatively rare in in- 
fants' stools and that their presence is often associated with 
symptoms of indigestion. 

Ibrahim * and Brennemann 2 observed that the casein curds 
appeared in the stools of babies fed on raw milk and disappeared 
from the stools when the milk was boiled. They both suggest boil- 
ing as a therapeutic measure for preventing the formation of such 
curds. This fact explains why casein curds are seldom seen in 
Germany where the milk is almost universally boiled. 

Ibrahim observed that the curds seem to come more easily in 
babies with digestive disturbances, but that they may come in 
otherwise healthy babies who are fed on raw milk. He saw them 
in a two and one-half year old child which had a typical " digestion- 
insufficiency " as described by Heubner. 3 The most recent experi- 
ments of Uffenheimer 4 seem to indicate that casein is present in 
the stools more frequently than was formerly thought, as it has 
been found in the salve-like skimmed milk stools. 

Selter 5 described a picture of "intoxication" in which there 
is an excursion of temperature from 37° to 34° {%. e., subnormal), 
slow pulse and superficial respiration. The color of the skin is 
bluish-gray. The urine contains no reducing substance. The 
stools are curdy and grayish-yellow, with a cheesy odor. The 
urine contains a kenotoxine, which, when injected into mice, 
causes a condition similar to that described in the babies. The 
disease is cured by small amounts of breast milk, or by carbohy- 
drates, and is attributed to the proteins. Monrad 6 and Morse 7 
do not believe with Finkelstein and his followers that casein is 
absolutely harmless, but think that it can cause dyspepsia. 

Holt and Levene 8 found that large quantities of casein given 
by mouth could cause a rise in temperature. They observed a rise 
in temperature in five instances that continued until the food was 
changed, and then subsided to normal. Fever occurred only when 
their " synthetic food " contained six per cent of casein. There was 

1 Ibrahim: Monatschr. f. Kinderh., 1911, x, 55. 

2 Brennemann: Am. Jour. Dis. Children, 1911, i, 341. 

3 Heubner: Verhandl. d. Gesellsch. f. Kinderh. in Salzburg, 1909, xxvi, 169. 

4 Uffenheimer: Sitzung der Miinchen Gesellsch. f. Kinderh., 1911; Miinchen 
med. Wochenschr., 1911, 876. 

6 Selter: Deutsch. med. Wochenschr., 1908, 512. 

6 Monrad: Monatsschr. f. Kinderh., 1911, x, 244. 

7 Morse: New York Med. Jour., 1913, xcvii, 477. 

8 Holt and Levene: Med. Klin., 1913, ix, 258. 



AND INFANT FEEDING 45 

a retention of chlorides for three or four days preceding the rise 
in temperature. They call attention to the parallelism between 
this fever and that produced by Vaughan by the paraenteral 
injection of protein. Their food contained a large amount of salts, 
however, and it is possible that the fever may have been caused 
by them. 

ANAPHYLAXIS 

The connection between anaphylaxis and the disturbances 
caused by cow's milk has always been a field for speculation. 
Hamburger * believed that foreign protein ("artfremdes Eiweiss") 
was "an irritant to the especially sensitive cells of the infant's 
alimentary tract and that the necessity of breaking down the 
protein molecule to such simple substances that they could not 
be injurious after absorption threw an added burden on the 
digestion and one which was unnecessary with milk of the same 
species." Howland 2 has brought forward some evidence against 
this theory. Recent investigations, however, have added posi- 
tive evidence. Moro and Bauer 3 found precipitines in the 
blood of marantic infants in a few instances. There is not much 
doubt that during the first weeks of life a foreign protein can 
pass through the intestinal wall. Schloss 4 and Berger 5 have 
given indirect, but suggestive evidence by differential counts of 
the blood, that when a foreign protein is introduced for the first 
time into the gastrointestinal canal of infants, there is a similar 
reaction in the body to that obtained in active sensitization and 
immunity of the body. These two pieces of work suggest that the 
sequence of sensitization and immunity takes place when any for- 
eign protein is introduced into the intestinal canal. Lust 6 fed 
different forms of foreign protein to children with digestive dis- 
turbances and found by the precipitine reaction that egg albumen 
passed through the intestinal wall in nine of sixteen cases of acute 
and chronic nutritional disturbances, while ox serum passed through 
in only one of seventeen cases. Hahn 7 found that in five out of 

1 Hamburger: quoted by Howland, — Am. Jour. Dis. Children, 1913, v. 390. 

2 Howland: Am. Jour. Dis. Children, 1913, v. 390. 

3 Moro and Bauer: quoted by Howland, — Am. Jour. Dis. Children, 1913, 
v. 390. 

4 Schloss: Paper read at the Am. Assoc, for the Study and Adv. of Clinical 
Investigation, May 11, 1914. 

5 Berger: Paper read at the Thirty-fifth meeting of the New England Pedia- 
tric Society, held January 29, 1915. 

6 Lust: Jahrb. f. Kinderh., 1913, Ixxvii, 383. 

7 Hahn: Jahrb. f. Kinderh., 1913, Ixxvii, 405. 



46 DISEASES OF NUTRITION 

twenty-three infants with acute nutritional disturbances antitoxin 
passed from the intestine into the blood. Modigliani and Benini x 
found by means of the precipitine reaction that the blood of 
infants fed on cow's milk showing symptoms of gastrointestinal 
disturbances, was always positive for cow casein. Sick new-born 
babies gave a positive reaction, while older breast-fed babies were 
negative even when they were given a little cow's milk during an 
acute intestinal disturbance. No healthy infants gave positive 
reactions. Vaughan 2 calls attention to the fact that peptone and 
other products of decomposition of protein may cause symptoms of 
disease and that " sensitization may result from the absorption of un- 
digested or partially digested proteins from the alimentary tract." 

Differences in the Absorption of Human and Cow's Milk Ni- 
trogen. — In most instances less nitrogen is taken in the food of 
naturally fed babies than in that of artificially-fed ones, but when 
approximately the same amounts of each are ingested there is less 
fecal nitrogen in the artificially-fed babies than in those fed natu- 
rally. 3 The nitrogen in the feces of both naturally and artificially-fed 
babies increases, other things being equal, with an increase of ni- 
trogen in the food. There may, however, be considerable varia- 
tions in the nitrogen excreted by the same child on the same food 
if the observation is continued over a long period of time, as is 
shown by the work of Cronheim and Miiller. 4 

Starvation stools. — Experiments on animals and man have 
shown that during starvation there are only small amounts of nitro- 
gen in the feces, that when a nitrogen-free food is given there is con- 
siderable increase in the fecal nitrogen 5 and that there may be more 
nitrogen in the stools on a nitrogen-free food than on one contain- 
ing a large amount of nitrogen. It may be assumed, therefore, 
that the animal albumins are probably completely or almost en- 
tirely absorbed in health. It is evident also that the nitrogen in 
the feces comes principally from the intestinal secretions and the 
intestinal bacteria. Keller 6 found that a baby excreted 0.74 gm. 
nitrogen per day in one experiment and 0.097 gm. in another, 
while undergoing starvation. 

1 Modigliani and Benini: Policlinico, Rome, Dec. med. Section, 1914, 
No. 12, 533. 

2 Vaughan: Jour. Am. Med. Assoc, 1913, lxi, 1761. 

3 See Tables in Keller: Phosphor, und Stickstoff im Sauglingsorganismus. 
Arch. f. Kinderh., 1900, xxix, 1; and Orgler: Ueber Harnsaureausscheidung im 
Sauglingsalter. Jahrb. f. Kinderh., 1908, lxvii, 383. 

4 Cronheim and Miiller: Biochem. Zeitschr., 1908, ix, 76. 

5 Rubner: Zeitschr. f. Biol., 1879, xv, 115, and others. 

6 Keller: Arch. f. Kinderh., 1900, xxix, 1. 



V 



AND INFANT FEEDING 47 

It would be expected that when the amount of food is increased 
there would be an increased flow of digestive juices, but figures do 
not bear out this assumption. Vegetable nitrogen is digested and 
absorbed with greater difficulty than animal nitrogen. Wohlge- 
muth 1 found that he could cause an increased flow of pancreatic 
juices in a man with a pancreatic fistula by feeding carbohydrates 
and that protein caused a less profuse flow. 

THE METABOLISM OF PROTEIN 

Schlossmann and Murschhauser 2 investigated the fasting metab- 
olism of infants. Their paper should be consulted in the origi- 
nal for the literature and the details of the investigations. They 
found that the nitrogen excretion in the urine during fasting 
depended upon the quality of the food ingested before fasting was 
commenced and that the greater the protein (nitrogen) content 
of the food, the greater was the excretion of nitrogen. For ex- 
ample, Baby 14: — 

TABLE 13 

Nitrogen content of urine per Nitrogen content of urine per 

hour, per kilogram hour per kilogram 

Grams Grams 

Feeding with human milk. . . .0.00363 Modified cow's milk 0.0119 

On first day of fast 0.00513 First day's fast 0.0160 

On second day of fast 0.00686 Second day's fast 0.0151 

On third day of fast 0.01083 Food again given 0.0080 

On first day after fast 0.0068 

On second day after fast . 0042 

When human milk had been used less body protein was broken 
down during starvation than when modified cow's milk was used. 
After eighteen hours of fasting the nitrogen in the urine represents 
the products of the katabolism of the body protein. The acetone 
bodies increase in the urine during fasting, and the evidence points 
to the absence of carbohydrate in the food as the cause. 

When the amount of protein in the food is increased there is 
increased retention of nitrogen. 3 Babies, unlike adults, are able 
to retain nitrogen even when they are not receiving the required 
number of food calories. They may continue to do so even under 
the most discouraging circumstances. 

In adults when the total carbohydrate of the food is replaced by 

1 Wohlgemuth: Berl. klin. Wochenschr., 1907, 47. 

a Schlossmann and Murschhauser: Biochem. Zeitschr., 1913, lvi, 355. 

3 Meyer, L. F.: Biochem. Zeitschr., 1908, xii, 422. 



48 DISEASES OF NUTRITION 

fat of an equal caloric value there is a considerable albumen def- 
icit. 1 If only a part of the carbohydrate is replaced by fat, 
the body will eventually return to a nitrogenous equilibrium. 
Orgler believes that in normal babies, however, the amount of fat 
in the food influences the nitrogen metabolism to only a slight 
degree. Increasing the fat in the food of babies that do not digest 
fat well may, on the other hand, result in a negative nitrogen 
balance. It is not known whether the action of the fat of human 
milk and of cow's milk is the same or not. In Courtney's cases 2 
the nitrogen retention was higher in those babies which showed a 
very considerable gain in weight in the course of the experiment 
and were, therefore, in the stage of reconvalescence. Fat does 
not seem to have the property of sparing protein. 

Carbohydrates, on the other hand, have a marked property of 
sparing nitrogen. 3 Cane and milk sugar have the same action 
as malt sugar. When they are added to the food there Is usually 
an increase in the nitrogen retention. When carbohydrates are 
given in excess, they cause increased peristalsis, frequent stools and 
a considerable loss of nitrogen from the body. 4, 5 

The growing body requires protein from which to build up the 
body tissues, muscles, etc., while carbohydrates and fats are used 
as fuel. It is obvious, therefore, that more protein or nitrogen 
must be ingested than is excreted in order that the needs of the 
growing tissues may be supplied. The osseous system, in the same 
way, requires mineral salts for its growth, and more salts must be 
ingested in the food than are lost in the excreta. These salts which 
are retained in the body are used to build up new bone. When the 
baby is gaining weight and strength, there is a retention of both 
nitrogen and salts and when the baby is not gaining, there may be 
a loss of both of these bodies. When one is retained in the body the 
other is apt to be retained, and vice versa, as shown by Orgler's 
baby No. 9. 6 

The metabolism of breast-fed babies can be compared more 
easily than that of bottle-fed babies because the food, i. e., breast 
milk is essentially the same in all cases, while that of artificially- 
fed babies differs a great deal. Orgler found that in general there 
is more nitrogen retained per kilogram of body weight in young 

1 Landergreen: Skandin. Arch. f. Physiol., 1903, xiv, 112. 

2 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

3 Keller: Maltsuppe, eine Nahrung fiir magendarmranke Sauglings. Jena, 
1903. 

4 Orgler: Jahrb. f. Kinderh., 1908, lxvii, 383. 

6 Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 

6 Meyer, L. F.: Ergebniss d. inn. Med. und Kinderh., 1908, i, 317. 



AND INFANT FEEDING 49 

babies than in older babies; that is, the retention decreases as 
the baby grows older. 

Both the retention and the utilization of nitrogen must be taken 
into consideration when the various cases in literature are com- 
pared. Utilization represents the amount retained as compared 
with the amount in the food. The following table taken from 
Schwarz gives an idea of utilization: 





TABL 


E 14 




Age 


Up to 14 days 


2-3 months 


5 months 


Retention 


0.351 

78.3% 


0.153 

40.8% 


048 


Utilization 


23.1% 



The foregoing table shows that the younger the baby is, the 
greater is the retention and utilization of nitrogen. This cor- 
responds with clinical observations of growth, for the very young 
baby grows very rapidly and, therefore, retains and uses more 
nitrogen in building up new body tissues than the older baby 
which does not increase so rapidly in size. Under certain con- 
ditions of under-nourishment, an increase in the amount of nitro- 
gen in the food results in an increased retention of nitrogen and 
improvement in the general condition of the baby. In other 
conditions an increase of the food nitrogen causes greater retention 
but not necessarily a gain in weight. There is no explanation of 
why this increase in the retention of nitrogen does not necessarily 
benefit the baby. Sick infants cannot retain as much nitrogen as 
well babies of the same age. Fife and Veeder 1 found that two 
cases of infantile atrophy had a greater retention of nitrogen than 
normal babies of the "same age and weight." The question may 
be raised, however, as to whether the babies examined could have 
been atrophic if they were of the same weight as normal babies of 
the same age. When the amount of carbohydrate in the food was 
increased there was increased retention of nitrogen but the nitro- 
gen retention was not influenced by the amount of fat in the food. 

Czerny and Steinitz 2 have collected the figures of the nitrogen 
metabolism of infants with disturbances of digestion and found 
that the absorption was approximately normal except during 
diarrhea. Although the evidence all seems to show that there is a 

1 Fife and Veeder: Am. Jour. Dis. Children, 1911, ii, 19. 

2 Czerny and Steinitz : Stoffwechselpathologie des Kindes, Noorden's Hand- 
buch d. Path. d. Stoffwechsels, II, 391. 



50 DISEASES OF NUTRITION 

retention of nitrogen in practically all instances, yet this evidence is 
not sufficient to warrant its acceptance without reserve. Gamble l 
has shown that in alkaline stools twenty per cent of the nitrogen 
can be lost in the form of ammonia during the process of drying. 
This loss of nitrogen has not been taken into consideration in the 
metabolism experiments of other writers and might be sufficient 
to result in a negative balance of nitrogen in some of the instances 
in which the balance has been reported positive. 

1 Gamble: Am. Jour. Dis. of Children, 1915, ix, 519. 



AND INFANT FEEDING 51 



CHAPTER V 
THE METABOLISM OF THE MINERAL SALTS 

The metabolism of the mineral salts was first investigated by 
Liebig 1 in 1840. Very little information of value in relation to 
the problems of infant feeding and metabolism has been added 
since then, however, until recent years. Even such information 
as we now have is being continually modified or disproved by 
chemists, who find that the methods which were employed in ob- 
taining the figures gave erroneous results. Summaries of the 
present knowledge of the metabolism of the mineral salts are 
given by Albu-Neuberg, 2 L. F. Meyer, 3 Hoobler, 4 and Tobler and 
Bessau. 5 

The body of the new-born infant is relatively richer in water 
and fat and poorer in nitrogen and ash than the body of the adult. 
The body of the fetus contains a very large proportion of water, 
the proportion diminishing as the fetus grows older. The com- 
position of the ash of the new-born infant is according to Soldner 6 
as follows : 

In one hundred parts of the new-born infant there is K2O, 
7.06; Na 2 0, 7.67; CaO, 38.08; MgO 1.43; M 2 3 , 0.11; F 2 3 , 0.83; 
Mn 3 4 , 0.03; S 2 5 , 37.66; So 3 , 2.02; CI, 6.61; Si0 2 , 0.06; Co 2 , 0.53. 

Human milk contains, with the exception of iron, much less 
of the mineral salts than cow's milk. More of the salts in human 
milk are in organic combination than in cow's milk and for that 
reason are supposed to be utilized more easily. Soldner 7 found 
that the sodium, potassium, and chlorine content of human milk 
decreased as lactation progressed, while the bone-forming con- 
stituents, calcium, magnesium and phosphorus, remained fairly 
constant. 

1 Liebig: Chemie in ihre anwendungs fur Agrikultur und Phys. 1876. 

2 Albu-Neuberg: Mineralstoffwechsel, Berlin, 1906. 

» Meyer, L. F.; Ergebnisse d. inn. Med. u. Kinderh., 1908, i, 317. 

4 Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. 

5 Tobler and Bessau: Allgemeine Pathologische Physiologie der Ernahrung 
und des Stoffwechsels im Kindesalter, Wiesbaden. 

6 Soldner: quoted in Pfaundler and Schlossmann: The Diseases of Children, 
Phila. and London, 1908, i, 364. 

7 Soldner: loc. cit. 



52 DISEASES OF NUTRITION 

The mineral salts play a very complicated part in digestion, 
because they are not only absorbed by the intestines, but also 
may be re-excreted into the digestive canal. There are also com- 
plicated reactions which take place between the organic and in- 
organic food components. 

The digestive juices contain salts. Bile contains from 3^ to 
1% of ash, which is especially rich in sodium and chlorides. 1 It 
also contains smaller amounts of potassium, calcium, and mag- 
nesium in combination with phosphoric acid. The pancreatic 
juices contain J^% of ash, the greater part of which is in the form 
of sodium carbonate. The intestinal secretions are also rich in 
carbonates. 

Metabolism of Ash. — Cow's milk contains much more ash 
than human milk, and, therefore, much more salt is given to the 
infant taking an artificial food prepared with cow's milk than it 
requires. The breast-fed infant 2 absorbs about 80% of the ash in 
the food and retains between 40% and 50% while the artificially- 
fed infant absorbs from 43% to 78% and retains from 43% 3 to 
none at all or may even loose ash from the body. 4 Hoobler 3 found, 
in his experiments, that the retention of mineral salts as compared 
with the retention of nitrogen was relatively poor. The retention 
was poorest when the food contained but little fat, was better 
when it contained a medium amount of fat, and was best when 
it contained a large amount of fat (5.4%). Talbot and Hill 4 
kept the fat and protein in the food approximately the same in 
seven periods, and found that when the carbohydrate was increased 
beyond the limit of tolerance and diarrhea resulted there was a 
loss of ash from the body. The increased excretion of ash was 
through the feces. 

Metabolism of Calcium. — The metabolism of calcium is de- 
scribed in detail in the chapter on rickets. For that reason it is 
unnecessary to speak of it here except to say that some investiga- 
tors criticise the methods which were used to quantitate the 
amount of calcium and show that they are inaccurate. 

Metabolism of Iron. — The amount of iron in both cow's milk 
and human milk is small and is insufficient for the needs of 
the growing infant. Nature has deposited enough iron in the 
liver 5 of the new-born infant, however, to last it until it can digest 

1 Tobler: loc. cit. 

2 Blauberg: Zeitschr. f. Biol., 1900, xl, 1. 

3 Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. 

* Talbot and Hill: Am. Jour. Dis. Children, 1914, viii, 218. 
6 Bunge: Zeitschr. f. physiol. Chemie, 1889, xiii, 399. 



AND INFANT FEEDING 



53 



foods which contain sufficient amounts of iron. The iron in human 
milk is apparently more easily retained than that in the milk of 
animals. The following table of Krasnorgorski 1 illustrates this 
point. 

TABLE 15 
Iron Metabolism of the Same Baby in two Periods 



Author 


Food 


Iron in 
food 


Feces 


' Urine 


Ab- 
sorbed 
mg. 


Ab- 
sorbed 
% 


Re- 
tained 
mg. 


Re- 
tained 
% 


Krasnor- 
gorski 

Krasnor- 
gorski 


Human milk 
Goat's milk 


7.05 mg. 
3.44 " 


0.84 mg. 
2.59 " 


0.55 mg. 
0.09 " 


6.21 
0.85 


88.09 

24.71 


5.66 

0.76 


80.28 
22.09 



Metabolism of Magnesium. — The absorption and retention 
of magnesium are higher in the breast-fed than in the artificially- 
fed infant. Hoobler l found that when an infant was taking an 
artificial food the retention was better when there was a low per- 
centage of fat in the food than when there was a high percentage 
of fat. 

Metabolism of Phosphorus. — One litre of human milk contains 
from 0.31 to 0.45 grams of phosphorus and one litre of cow's milk 
about 1.81 grams. Three-quarters of the phosphorus in human 
milk is in organic combination, while only one-quarter of the phos- 
phorus in cow's milk is in organic combination; 41.5% of the 
total phosphorus in human milk is in the form of nucleon phos- 
phorus and only 6% in cow's milk. 

According to Blauberg 2 89.2% of the phosphorus in human 
milk and 53.2% of that in cow's milk is absorbed. Hoobler 3 found 
that more was absorbed when the food contained a high per cent, 
than when it contained a low per cent, of fat. Knox and Tracy 4 
confirmed the work of Keller showing that the bottle-fed baby 
excretes much more phosphorus in the urine than the breast-fed 
infant. The latter excretes very little or none. According to 
L. F. Meyer, 5 the retention of phosphorus is less in the artificially- 
fed than in the breast-fed infant, the former retaining about 30% 
of the intake and the latter 69.13%. 

1 Quoted by L. F. Meyer: Ergeb. d. inn. Med. u. Kinderh., 1908, i, 
327. 

2 Blauberg: see Hoobler, loc. cit. 
* Hoobler: loc. cit. 

4 Knox and Tracy : Am. Jour. Dis. Children, 1914, vii, 409. 

5 Meyer, L. F. : Ergeb. d. inn. Med. u. Kinderh., 1908, i, 317. 



54 DISEASES OF NUTRITION 

Metabolism of Sodium and Potassium. — There is more potas- 
sium than sodium in milk. Human milk contains less sodium and 
potassium than cow's milk. The absorption of these salts is good 
for both milks. The retention is better on human milk than on 
cow's milk, being 67% for sodium and 74% for potassium on 
human milk, while on cow's milk it is 15.27% for sodium and 
16.12% for potassium. Both salts are eliminated in both the urine 
and feces, from 15% to 25% of the intake being eliminated in the 
feces. 1 

Metabolism of Chlorides. — Very little is known about the 
metabolism of the chlorides. 

Metabolism of Sulphur. — Hoobler finds that the sulphur of both 
human and cow's milk is well absorbed, the absorption taking place 
principally in the small intestine. Sulphur is eliminated almost en- 
tirely through the urine, but a small part is eliminated into the large 
intestine. The retention of sulphur is better when human milk 
is taken than when cow's milk is taken. 

The Influence of the Various Food Components on the Me- 
tabolism of the Mineral Salts. — There are very few investigations 
which throw any light on the influence of the individual food 
components on the metabolism of the mineral salts. 

Howland 2 found that carbohydrates increased the retention of 
calcium. 

L. F. Meyer found that the addition of casein to the food di- 
minished the absorption of all the mineral salts. 

Steinitz 3 Rothberg 4 and Birk 5 found that as the fat in the 
food was increased the loss of mineral salts in the feces was also 
increased. This loss was especially of calcium and magnesium 
and sometimes resulted in a negative balance. Courtney 6 on the 
other hand, did not find that fat had any marked influence on the 
retention of ash in infants with chronic indigestion. 

L. F. Meyer 7 found that infants with " Bilanzstorung " lost 
from 34% to 60% of the ash in the food through the feces as com- 
pared with from 20% to 25% in normal cases. In the stage of in- 
toxication he found that more sodium, potassium, and chloride were 

1 Hoobler: Am. Jour. Dis. Children, 1911, ii, 107. See table and references. 

2 Howland (not yet published). Read before the Am. Ped. Soc'yj Wash., 
1913. 

3 Steinitz: Monatsschr. f. Kinderh., 1902-3, i, 225; Jahrb. f. Kinderh. 1903, 
lvii, 689. 

4 Rothberg: Jahrb. f. Kinderh., 1907, lxvi, 69. 

5 Birk: Jahrb. f . Kinderh., 1907, lxvi, 300. 

6 Courtney: Am. Jour. Dis. Children, 1911, i, 321. 

7 Meyer, L. F.; Jahrb. f. Kinderh., 1910, lxxi, 379. 



AND INFANT FEEDING 55 

lost in the feces but that there could still be a retention of calcium 
and phosphorus. There is always a loss of ash from the body 1 in 
acute diarrhea, although even under these circumstances a reten- 
tion of calcium is possible. The reverse is apparently true when 
"soap stools" are passed. 

1 Tobler and Bessau: loc. cit. 



56 DISEASES OF NUTRITION 



CHAPTER VI 
THE ENERGY METABOLISM OF INFANTS 

The earliest investigation of the gaseous metabolism of infancy 
is that reported by J. Forster, of Munich in 1877. 1 He found 
with the large Pettenkofer-Voit respiration chamber that the in- 
fant produces much more carbon dioxid per unit of weight than 
does the adult. In France Richet, Langlois, Variot and Saint- 
Albin, Bonniot, Variot and Lavaille 2 and C. Weiss published a 
series of investigations on the metabolism of new-born infants 
and atrophic infants between the years 1885 and 1912. In 1898 
the classical monograph of Rubner and Heubner 3 appeared. 
They studied the average daily requirement of food of a normal 
infant and in the following year 4 of an atrophic infant. They 
point out the fact that in human beings the carbon dioxid excre- 
tion is proportional to the body surface, whatever their size. 

In 1908 the first of a series of investigations by Schlossmann and 
Murschhauser 5 appeared, and this, with subsequent articles, 
the last of which was published in 1914 6 have added much to our 
knowledge of the metabolism of infancy. These authors emphasize 
the influence of muscular activity on metabolism and they studied 
the basal metabolism (Grundumsatz) during complete repose for 
the purpose of comparing the metabolism in health and disease. 
They conclude that slight changes in the temperature of the sur- 
rounding air are without influence on the metabolism. Their in- 
vestigations led them to study also the fasting metabolism in order 
to eliminate the influence of work done during digestion. 

Other investigators, whose names should be mentioned, are 
Mensi, Poppi, Scherer 7 Babak, and Hasselbach, Barhdt, Birk, 
Edelstein and Niemann. 

1 Forster: Amtl. Ber. d. 50 Versammlung deutsch. Naturforscher u. Aerzte 
in Miiiichen, Munich, 1877, 355. 

2 For synopsis of literature see Benedict and Talbot : Gaseous Metabolism of 
Infants, Carnegie Institution of Washington, Publication 201. 

3 Rubner and Heubner: Zeitschr. f. Biol., 1898, xxxvi, 1. 

4 Rubner and Heubner: Zeitschr. f. Biol., 1899, xxxviii, 315. 

5 Schlossmann and Murschhauser: Biochem. Zeitschr., 1908, xiv, 385. 

6 Schlossmann and Murschhauser: Biochem. Zeitschr., 1914, lviii, 483. 

7 See Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 



AND INFANT FEEDING 57 

In America, Carpenter and Murlin * studied the energy metab- 
olism of pregnant women before and after the birth of the child. 

Howland 2 studied the direct calorimetry and compared it 
with the heat calculated from the carbon dioxid excretion and 
oxygen consumption. He found that the heat-production as di- 
rectly measured and as indirectly computed was strikingly close, 
the greatest difference being two. per cent. Benedict and Talbot 3 
reported from the Nutrition Laboratory of the Carnegie Institution 
of Washington in 1914, the results of three years' investigations 
with a respiratory chamber on about eighty babies, of which 
sixty-one were reported in detail. Murlin and Hoobler 4 reported 
the results of their investigations with a respiratory chamber on a 
few infants in 1915. 

Methods of Computing the Energy Metabolism. — There are 
several ways of computing the energy metabolism of infants: 
first, by measuring the heat lost by an infant in a calorimeter; 
second, by computing the heat production by collecting the 
carbon dioxid excreted and measuring the oxygen consumed by an 
infant in a respiratory chamber. Zuntz 5 has computed the cal- 
orific value of oxygen with different respiratory quotients and these 
figures may be considered to-day as the best data we have for the 
computation of the energy output from the measurement of the 
gaseous exchange. Knowing the respiratory quotient the calcula- 
tion of the calorific value of carbon dioxid is a simple one. (Bene- 
dict and Talbot, Carnegie Institution of Washington, Publication 
201, Table fifteen, page twenty-nine, gives the calorific equiva- 
lents of carbon dioxid.) 

It is, therefore, possible to determine how many calories are used 
during a given period when the carbon dioxid and the respiratory 
quotient are known ; thirdly, the energy metabolism has been com- 
puted by investigators who have measured the fat, carbohydrate 
and protein intake and the loss of fat, carbon and nitrogen in the 
excreta; and finally, the energy metabolism is roughly computed 
by clinicians who know the approximate or theoretical composi- 
tion of the elements in the food. The last method is of little or no 

1 Carpenter and Murlin: Arch. Internal Med., 1911, vii, 184. 

2 Trans. Fifteenth Internat. Cong. Hyg. and Demog., 1911, ii, 438. 

3 Benedict and Talbot: Carnegie Institution of Washington, Publication 201; 
and Am. Jour. Dis. Children, 1914, viii, 1. 

4 Murlin and Hoobler: Am. Jour. Dis. Children, 1915, ix, 81. See also Bailey 
and Murlin, Am. Jour, of Obstetrics and Dis. of Women and Children, 1915, 
lxxi, 526, for the Metabolism of New-born Babies. 

5 Zuntz, quoted by Benedict and Talbot : Carnegie Publication of Washing- 
ton, No. 201, 1914. 



58 DISEASES OF NUTRITION 

scientific value since the composition of the food varies even when 
the greatest precautions are taken to keep it uniform. It is of 
value only to the clinician in his practical work and may give false 
information. 

Howland, working i'n Professor Lusk's Laboratory at Cornell 
University Medical School, showed in a very brilliant way that 
the output of heat when measured directly and when computed 
from the carbon dioxid and oxygen, coincided very closely. The 
greatest difference was two per cent. Other investigations, in 
which the heat was computed from the carbon dioxid and oxygen, 
are, therefore, within very small limits of error. 

The Effect of Muscular Exercise on Metabolism. — Schloss- 
mann appreciated the fact that muscular exercise caused a marked 
increase in the heat production of an infant. Howland found 
a difference of 17.6% and 39% in the heat production between 
periods of quiet sleep and active struggling and crying, while 
Murlinand Hoobler found that hard crying may increase the metab- 
olism as much as 40%. Benedict and Talbot found that an in- 
crease of 60% was common and that there could be an increase 
of 100% (as in the case D Q Dec. 22 : ) from quiet sleep to active 
exercise. It is obvious, therefore, that a comparison of the metab- 
olism of an active healthy infant with that of a quiet sick infant 
is of no value, because in one the effect of muscular activity is 
added to the basal metabolism and in the other it is not. The 
basal metabolism, that is, the metabolism during complete mus- 
cular repose, should be always used when health and disease are 
compared. 

The Effect of Fasting on the Metabolism. — There is evidence 
which seems to show that the metabolism of infants after taking 
food is always higher than it is in the same infant while fasting. 2 
Howland, 3 in commenting on one of his experiments says: "This 
experiment, so far as one can do so, brings additional proof to the 
view that insufficient food reduces the carbon dioxid excretion, 
but that after eighteen hours, a fasting metabolism is not reached 
with infants, as shown by the normal heat production and by the 
respiratory quotient of 0.81." Schlossmann and Murschhauser 2 
found that after eighteen hours of fasting acetone soon appears 
in the urine in considerable quantities. The question can be 
raised, therefore, whether an infant, which has been starved more 

1 Benedict and Talbot: Carnegie Institution of Washington, Pub. 201, p. 97. 

2 Schlossmann and Murschhauser: See Murschhauser, Boston Med. and 
Surg. Jour., 1914, clxxi, 185. 

3 Howland: Tr. Fifteenth Internat. Cong. Hyg. and Demog., 1912, ii, 438. 



AND INFANT FEEDING 59 

than twenty-four hours and whose urine contains considerable 
quantities of acetone, can be considered normal. Benedict and 
Talbot x studied the fasting metabolism of several infants at periods 
from three to twenty-four hours after food had been given. They 
found that the respiratory quotient was markedly lowered after 
eighteen hours of fasting. The figures of heat production obtained 
were inconsistent, because it was almost impossible to obtain half 
hour periods for study in which the fasting infant was in complete 
muscular repose. If the metabolism is lower after eighteen or 
twenty-four hours' fast than it is directly after taking food, it must 
be only slightly diminished. Further investigations must be car- 
ried on to decide at which point the metabolism of a fasting infant 
changes from a physiological condition into a pathological condi- 
tion. For this reason recent investigations have been confined 
almost entirely to measuring the metabolism directly after food 
has been given. 

Comparison of Body Surface and Metabolism. — For many 
years writers on metabolism have been wont to emphasize the 
significance of the relationship supposed to exist between the 
metabolism and the body surface rather than that between the 
metabolism and the body weight. The idea that there is an inti- 
mate relationship between body surface and heat production was 
first brought out by Bergmann 2 in 1847. The theory lay dormant 
for many years, but was finally resuscitated and put forth in a 
brilliant and highly stimulating manner by Rubner 3 in 1883, to- 
gether with experimental evidence. Based fundamentally on 
Newton's law of cooling, it received great attention from prac- 
tically all workers in physiology. The startling evidence which 
was brought forward to demonstrate that the heat production 
per square meter of body surface was about 1,000 calories for 
practically all species of animals lent further support to this hy- 
pothesis. 

The researches of Benedict and Talbot, 4 confirmed by Murlin 
and Hoobler, 5 show that such conclusions are not warranted since 
the relation between the basal metabolism of infants and the 
body surface is not uniform. The following chart illustrates this 
point: 

1 Benedict and Talbot: Carnegie Institution of Wash., Pub. 201. 

2 Bergmann and Leuckart: Anatomisch-physiol. Uebersicht des Thierreichs, 
Stuttgart, 1852, 272; Bergmann: Warmeokonomie der Thiere, Gottingen, 
1848, 9. 

3 Rubner: Ztschr. f. Biol, 1883, xix, 545. 

4 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 

5 Murlin and Hoobler: Am. Jour. Dis. Children, 1915, ix, 81. 



60 



DISEASES OF NUTRITION 



CHART I (Benedict and Talbot) » 

Chart showing actual body weight of infants and heat production per square 
meter of body-surface (Meeh formula) per twenty-four hours 

HEAT PER SQUARE METER (MEEH) PER 24 HOURS 













HT 




EG* 


RS * 






































EK 




















EF 












RL 

• 

PW s 
























A3 




RA 
MC * 


MO- 






PS» 












EM 










MM ( 




LRB 


RE, 


• 
MA e 
EN 


FK .. 
BF 


JP 

• 
• DM 








A 






UH 


RC 

• 


FR 

• 






BO* 


ER» 


• FD 

LB 


WP. 


CN 
• JS 
EL • 


• 
TC 


• 
FB 












TK 

RD« 


■ a.'.; 

oc 


MD* 


IR # 




G3 


KR -j 8 ' 


JO 

L AD 


•EC 


LO 


JM* • 
, FM 

HC 


• 


8 V 2 MOS. 












AC* 






•£H3 




ES 


































JV 3 1 / 2 


KOS. 



















575 625 675 725 775 



875 925 975 1025 1075 1125 1175 1225 1275 1325 1375 
CALORIES 



This chart shows that the basal metabolism per square meter 
of body surface varies over one hundred per cent, when new-born 
infants, viz., those lying to the left of the line marked 675 calories 
are included. They * conclude, — " that our evidence points 
strongly and conclusively to the fact that the active mass of 
protoplasmic tissue determines the fundamental metabolism. 
The absence as yet of a direct mathematical measure of 
the proportion of active protoplasmic tissue does not, we be- 
lieve, in any wise affect the convincing nature of our evi- 
dence." 

The total basal metabolism of an infant increases with its age 
and weight, as would be expected. On the following chart, taken 
from the paper by Benedict and Talbot, 1 the normal infants are 
indicated by crosses and the abnormal infants, including those that 
are under-weight, are indicated by dots. A hypothetical curve 
has been constructed for the normals that shows the tendency 
of the metabolism to increase with the weights of the infant. In 
general, those infants which weigh more than the average for the 
age lie above the curve while those which weigh less than the aver- 
age fall below the curve. 



1 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 



AND INFANT FEEDING 



61 



CHART II 

Chart showing the actual body weight of infants and the total heat produc- 
tion per twenty-four hours 

TOTAL HEAT PER 24 HOURS 



9.2 



7.6 



3.6 



2.8 





















HT 




EG 

X 




*rs 






















































•EK 














EF* 










RL 

xpw 


















AS 


^XJmc 


^ 


NO 




PS 






EM 












MM DO 

• 


LRB 


oMA 

•en 


F »« BF 

• JP 






•« 










FR -^ 






FD* 


•RE 

•CN 
• J9 


DM" 

TC 














TK^ 


RC 


'"V 




EC 


EL 
GM '.FM 


















if X 
AC* 


X 

oc 

EHS, 


GS . . 
KR* Jl 


••ad 

ES 


LO 


• 

jv ay 2 t 


03. 












































JV 


3 1 / 2 MOS 



























165 



195 



405 



435 



= NORMAL INFANTS 

= ABNORMAL INFANTS INCLUDING THOSE UNDERWEIGHT 



The comparison of the basal heat production per kilogram of 
body weight is of more practical interest to the clinician. 

Chart III on the next page is taken from the paper of Benedict 
and Talbot. 

In general, the babies weighing the average for the age and in all 
respects normal fall between the lines marked A and B or, roughly 
their basal metabolism is between 52 and 63 calories per kilogram 
of body weight. The normal infants, other than new-borns, that 
have a great deal of fat on their body in proportion to their muscu- 
lature, have a basal metabolism of between forty and a little more 
than fifty calories per kilogram of body weight. New-born infants 
are included in this class. Most of the infants that are under-weight 
have a basal metabolism of more than sixty-five calories per kilo- 
gram of body weight and, in general, the more they are under- 
weight, the greater is the basal metabolism. This chart shows 



62 



DISEASES OF NUTRITION 
CHART III 



Chart showing the actual body weight of infants and the heat production 
per kilogram per twenty-four hours 















HEAT PER KILOGRAM OF BODY-WEIGHT PER 24 HOURS 










A B 
















*RS 








- 










9.0 


HT 






• 

EG 














































8.0 








































EK 


























RL» 
















7.0 


EF« 












PW 

• 




















































• NO 






*PS 










o 

*6.o 

o 
U 

5 5.0 

H 

o 

< 

4.0 
8.0 










MC # 


•ra 














EM 






AS 
LL « 


LRB 


•dq 


MA 




FK . «BF 

»EN JP ' 


•DM 




• 
JM 




RC, 


FR 

• 


MO 






BD* 


FD 
ER 


RE 


CN' 

WP 
LB . 


JS " EL 

• 


• FB 

• 
TC 






TK 
RD # 


EP 

* IN* 


• 

oc 










GS 


KR J | 


EC 

• 

•jo 

AL 

• »AD 


GM 


• FM 
HC« 
• LO 


• 
JV 8/4 MOS. 










AC 






EHS 




ES 








2.0 


















































JV 3V£MOS. 



60 A 



that the basal metabolism per kilogram of body weight may vary 
one hundred per cent, in different infants. 

The Respiratory Quotient. — The respiratory quotient is the 
ratio between the volume of carbon dioxid expired and the volume 
of oxygen inspired during the same time, viz., vol. CO2 -r> ~ 

When carbohydrates are burned the respiratory quotient is unity, 
that is, for every hundred volumes of carbon dioxid excreted a 
hundred volumes of oxygen are absorbed. (The respiratory quo- 
tient for carbohydrates is 1.00.) The respiratory quotient for fat is 
0.713 and for protein 0.801. The respiratory quotient, when 
carefully determined, throws considerable light on the character 
of the materials burned in the body. 



AND INFANT FEEDING 63 

Caloric Values. — Rubner's " standard values" have been 
widely used throughout the world in determining the average fuel 
value of a mixed diet. They are : 

1 gram of protein 4.1 calories (large) 

1 gram of fat 9.3 calories (large) 

1 gram of carbohydrate 4.1 calories (large) 

The heats of combustion of the carbohydrates are as follows: 

Stohmann 1 Emery and Benedict 2 

Dextrose 3.692 3.739 

Lactose 3.877 3.737 

Saccharose 3.959 3.957 

Starch 4.116 

Since the carbohydrates used in infant feeding are usually sugars 
rather than starch, the caloric value of the carbohydrate would 
be more accurate if a lower factor were used, for instance, 3.7 for 
lactose. 

Computed Metabolism. 3 — The energy quotient is the term 
applied by Heubner 4 to the number of large calories per kilogram 
of body weight per day that are necessary for growth. The metab- 
olism of a large number of infants has been computed when the 
amount of fat, carbohydrate, or protein in the food was known, 
or in which averages of the various analyses of milk were taken. 
It has been shown by many investigators that the percentage com- 
position of human milk can vary within very wide limits, and ob- 
viously there must be a corresponding fluctuation in its caloric 
value. For this reason many of the computed energy quotients, 
based upon the average composition of human milk, are criti- 
cised. Heubner 5 concluded that a breast-fed infant did not gain 
satisfactorily on human milk during the first three months when 
the energy quotient fell below one hundred calories, and that 
when the energy quotient fell below seventy calories there must 
be a loss of weight. Schlossman 6 on the other hand found the 
best gain on an energy quotient of one hundred and ten calories. 
Premature infants and artificially-fed infants, according to Heub- 

1 Quoted by Lusk: The Science of Nutrition, Phila. and London, 1909, 41. 

2 Emery and Benedict: Am. Jour. Phys., 1911, xxviii, 301. Later they 
showed even a greater difference in the heat of combustion of lactose. 

3 An excellent review of the Continental work may be found in Frank : 
Energiequotient und Temperatur im Sauglingsalter. Inaug. Dissert. Munchen, 
1913. 

4 Heubner: Kinderh., 3 auflage, Leipzig, 1911, vol. I. 

5 Heubner: Jahrb. f. Kinderh., 1910, lxxii, 121. 

6 Schlossmann: Arch. f. Kinderh., 1902, xxxiii, 338. 



64 DISEASES OF NUTRITION 

ner, should have an energy quotient of not less than one hundred 
and twenty calories during the first three months of life. Feer * 
found that the energy quotient of Baby Marianne, the composi- 
tion of whose food was known, during the thirty-third to the 
forty-sixth week of life was between eighty-six and one hundred 
and four calories. He believes that the reason artificially-fed 
infants require more calories than the breast-fed is that the work of 
digestion is greater in the former than in the latter. Cramer 2 
studied the energy quotient of infants during the first nine days of 
life, and found a gain of from fifty to sixty grams with an energy 
quotient of less than fifty calories. Gaus 3 confirmed these findings 
and it was concluded that there was a special metabolism for in- 
fants during the first two weeks of life. 

Siegert 4 concluded that it was possible for the breast-fed infant 
to gain on eighty calories per kilogram of body weight during the 
first three months of life. Czerny and Keller 5 considered Heub- 
ner's figures too high and report an infant of average weight (Ma- 
chill) which gained regularly on an average of seventy calories per 
kilogram of body weight. A daily examination of the milk was 
not made. Bundin 6 fed a number of infants on mixtures of cow's 
milk which gave an energy quotient of seventy calories. These 
infants were of the average or of less than the average weight and 
gained weight consistently. Oppenheimer 7 gave an energy quo- 
tient of one hundred and eleven calories to a normally developed 
infant and as high as one hundred and forty-two calories to an 
infant which had previously been underfed. Beck, in 1904, 8 col- 
lected the literature up to date and gives the following figures as 
an average energy quotient for breast-fed infants : 

1-12 weeks 107 calories 

13-24 weeks 91 calories 

25-36 weeks 83 calories 

37-44 weeks 69 calories 

He concluded that artificially-fed and premature infants re- 
quired an energy quotient of from one hundred and twenty to one 

1 Feer: Lehrbuch der Kinderh., 2nd Ed., 1912. 

2 Cramer: Munch, med. Wochenschr., 1903, 2, L, 1153. 

3 Gaus: Jahrb. f. Kinderh., 1902, N. F. lv, 129. 

4 Siegert: Versamml. d. Gesellsch., f. Kinderh., Stuttgart, 1906. 

5 Czerny and Keller: Des Kindes Ernahrung, Ernahrungsstorungen, und 
Erhahrungstherapie, Leipzig and Wien, 1906, vol. i, 396. 

6 Bundin : See Czerny and Keller, p. 404. 

7 Oppenheimer: Arch. f. Kinderh., 1909, L. 355. 

8 Beck: Monatsschr. f. Kinderh., 1904-05, iii, 206. 



AND INFANT FEEDING 65 

hundred and forty calories. Ladd 1 gave an energy quotient which 
varies between ninety-three and one hundred and fifty-nine calories. 
Dennett 2 concluded that the average normal baby will do well on 
from one hundred and ten to one hundred and twenty calories per 
kilogram and that very emaciated babies require from one hundred 
and sixty to one hundred and seventy calories, while those who are 
only moderately emaciated require from one hundred and thirty 
to one hundred and fifty calories. Finally, Finkelstein, 3 Gittings, 4 
and Mayerhofer and Roth 5 drew attention to the fact that infants 
who were under-weight required more calories than well-developed 
infants and advanced the suggestion that they require as many 
calories as they would need if they had developed in the normal 
manner. 

The figures just given as to the clinical status of the caloric 
requirements of different infants show what a difference of opinion 
there is among the various authorities. There can be little doubt 
that in the main they are all correct, if one bears in mind the pos- 
sibility of error in such rough calculations of the energy metabolism 
of infants. Unfortunately, the accurate measurement of the 
energy metabolism in the calorimeter or by the respiratory ex- 
change is only for shorter or longer periods of the twenty-four 
hour day and does not give exact measurements of the twenty- 
four hour metabolism. It is necessary, therefore, to depend upon 
the knowledge of the basal metabolism of a large number of in- 
fants and to attempt to correlate this with the results of clinical 
experience. 

Summary. — The basal metabolism of an infant is the metab- 
olism determined after the taking of food, with the infant in com- 
plete muscular repose. Comparison of infants in different states 
of nutrition shows that roughly the normal infant, not the new- 
born, of the average weight for its age has a basal metabolism of be- 
tween fifty and sixty-five calories per kilogram of body weight, 
irrespective of age. This is the lowest amount of energy on which 
a baby can maintain its body functions. The habits of healthy 
infants vary with the individual. One is phlegmatic and sleeps 
most of the day and night, while another is moving, kicking or 
crying during most of its waking hours. It has been shown that 

1 Ladd: Archives of Pediatrics, 1908, xxv, 178. 

2 Dennett: Trans. Section on Dis. of Children, Amer. Med. Asso., 1912, 186. 

3 Finkelstein: Lehrbuch der Sauglingskrankheiten i, 54. 

4 Gittings: Am. Pediatric Soc, Stockbridge, 1914, Reported in Jour. A. M. 
A., 1914, lxiii, 55. 

5 Mayerhofer and Roth: Zeitschr. f. Kinderh., 1914, xi, 117. 



66 DISEASES OF NUTRITION 

the metabolism may be increased from forty to one hundred per 
cent above the basal metabolism by the change from complete 
muscular repose to active exercise. If forty per cent is added 
to the basal metabolism of fifty calories per kilogram, the result 
will be an energy quotient of seventy calories. It seems probable, 
therefore, that the infants studied by Czerny, Budin and their 
followers were placid infants who conserved their energy for 
development. If one hundred per cent is added to the basal 
metabolism, the energy quotient is between one hundred and one 
hundred and thirty calories. Such infants must either be very 
active to use up all this " extra steam" or else they must lose un- 
digested food or unabsorbed energy through the stools, or they 
must gain weight rapidly. It is probable, therefore, that Heubner 
and his followers dealt with more active infants than did the 
Czerny school. The concensus of opinion seems to be that breast- 
fed infants require less energy than the artificially-fed, because less 
energy is required to make the food available for the body. This 
may be the sole explanation, or it may be that the difference in 
their requirements is due to the fact that the breast-fed infant is 
on the average a quieter infant and that it sleeps more than the 
artificially-fed infant. 

Babies that weigh more than the average weight for their age 
and new-born infants have usually a basal metabolism of between 
forty and fifty-two calories per kilogram of body weight. Both the 
new-born and fat infants are quieter than infants which have 
developed their muscles and as a result the energy required for 
muscular work, which must be added to their basal energy metab- 
olism, is less than it is in active, crying infants. The large fat 
babies which weigh more than the average will, therefore, gain 
more weight on a low energy quotient than babies of average 
weight. The new-born infant falls into this class as it has a rela- 
tively large proportion of fat and a small proportion of muscle. 

Moderately emaciated or atrophic infants have a higher basal 
metabolism than do the babies of average weight. It varies be- 
tween sixty-three and eighty-seven calories per kilogram of body 
weight. When the energy required for muscular work is added to 
this, the energy quotient is the result. It must be remembered, 
however, that infants of this type that have many loose undigested 
stools may lose twenty per cent 1 or more of the energy of the food. 
If the infant is very weak and quiet, a small increase in the number 
of calories above the basal requirements will be sufficient to enable 
it to gain in weight. If, on the other hand, it is crying from morn- 
1 Benedict and Talbot: Am. Jour. Dis. Children, 1914, viii, 1. 



AND INFANT FEEDING 67 

ing to night because of either hunger or discomfort, a very much 
greater percentage of calories must be added to the basal require- 
ments in order that it may grow. There also can be little doubt 
that in weak babies energy, which would otherwise be used to 
keep the baby warm, can be conserved by increasing the tempera- 
ture of the infant's surroundings. The infant that is under-weight 
requires, therefore, somewhere between one hundred and thirty 
and one hundred and sixty calories per kilogram of body weight. 



68 DISEASES OF NUTRITION 



CHAPTER VII 
BACTERIOLOGY OF THE GASTROINTESTINAL CANAL * 

BACTERIOLOGY OF THE MOUTH 

The infant's mouth is sterile before birth, but becomes infected 
from the mother's vagina during birth, 2 or from the air soon 
after birth. 3 The variety of organisms present at this time is 
relatively small, but as soon as the infant commences to take 
food the flora becomes more complicated. The number of bac- 
teria does not, however, increase materially. When the infant 
takes breast milk, there is an increase in the variety of the or- 
ganisms, and pathological bacteria even may be found in the 
mouths of healthy babies. 4 Because of the fact that even the 
purest cow's milk contains more bacteria than human milk it is 
reasonable to expect that the mouths of babies fed on the bottle 
will contain a greater variety of bacteria than those fed at the 
breast and that the dirtier the milk the greater will be the variety of 
the organisms. There are, however, no data as to whether this is 
true or not. After the eruption of teeth, i. e., after the infant is six 
months old, the number and variety of the bacteria increase 5 and 
certain microorganisms, such as the Leptothrix, 6 and Fusiform 
bacteria, 7 which are apparently only able to obtain a foothold in 
the mouth when teeth are present, 8 appear. 

It is an open question as to how important a part the bacteria of 

1 G. Bessau in Tobler, Allegemeine Pathologische Physiologie der Er- 
nahrung imd des Stoffwechsels im Kindesalter, Wiesbaden, 1914, has been 
freely used in this chapter and many of the statements have been taken 
directly from it. It may be consulted by those who wish to go into the subject 
more deeply. 

2 Kneise: Sittler quoted by Tobler. 

3 Campo: La Pediatria, 1899, vii, 229. 

4 Doernberger: Jahrb. f. Kinderh., 1893, xxxv, 395; Herzberg: Deutch. med. 
Woch., 1903, xxix, 17. 

5 Noblecourt and Vicaris: Arch. gen. de Med., 1905, 2, 3201, ref. Monatssehr. 
f . Kinderh., 1905-6, iv, 640. 

6 Oshima: Arch. f. Kinderh., 1907, xlv, 21. 

7 Uffenheimer: Munch, med. Woch., 1904, 1198, 1253; Ergebnisse d. inn. 
Med. u. Kinderh., 1908, ii, 304. 

8 For a more detailed account of the flora of the mouth E. Kuster in Kolle 
Wasserman's - Handbuch, II ed., Jena, 1913, vi, 435, may be consulted. 



AND INFANT FEEDING 69 

the mouth play in the digestion processes in the stomach. It is con- 
ceivable that these bacteria, especially when there is dental caries, 
may do harm. It has not been proven, however, that they do. 

BACTERIOLOGY OF THE STOMACH 

The same influences which modify the bacterial flora of the 
mouth modify that of the stomach. Under physiological con- 
ditions the bacteria in the stomach play an unimportant role. 
A description of the individual kinds may be found in the works 
of Escherich 1 who was a pioneer in this field of investigation. 
The smallest numbers are found in the stomachs of the breast- 
fed, 2 and they remain relatively scarce as long as the digestion 
is normal. When there is indigestion, there is an increase in 
their numbers. The greatest numbers are found in cholera in- 
fantum. 3 

Bactericidal Powers of the Stomach. — Free hydrochloric acid 
is able to destroy bacteria in the stomach. 4 There is no doubt 
that it is strongly attracted by the proteins of the food and quickly 
combines with them, thus becoming inert. Furthermore, the casein 
in the milk is rapidly coagulated into curds. The disinfecting 
action of the hydrochloric acid can only be effective on the sur- 
face of the curds, and the large numbers of bacteria which are 
present in the interior of the curds are not reached by it. 5 The 
number of bacteria in the stomach apparently depends also on 
the activity of the gastric motility, for the quicker the stomach 
is emptied, the fewer are the bacteria which it contains. The 
converse is also true. 

Lactic acid fermentation does not seem to play as important a 
part in the stomach of the infant as it does in that of the adult in 
which it occurs only when hydrochloric acid is absent. Lactic acid 
is seldom or never found in the stomach of the breast-fed, but is fre- 
quently found in small amounts in the stomachs of infants fed on 
cow's milk. 5 

Butyric acid fermentation is more common, 6 and has been 
found to occur in the stomachs of atrophic infants in which the ex- 

1 Escherich: Die Darmbakterien des Sauglings, Stuttgart, 1886. 

2 Van Puteren- Ref. Zeitschr. f. mikroskopie, 1888, v, 539. 

3 Seiffert: Jahrb. f. Kinderh., 1891, xxxii, 392. 

4 Hamburger: Ueber die Wirkung des Magensaftes auf pathogene Bakterien. 
Inaug. Diss. Breslau, 1890, quoted by Tobler. 

5 Tobler: Ergeb. d. inn. Med. u. Kinderh., 1908, i, 495. 

6 Cassel: Arch. f. Kinderh., 1890, xii, 175. 



70 DISEASES OF NUTRITION 

cretion of hydrochloric acid and the motility are both diminished. 
The pasteurization or boiling of milk destroys the organisms which 
produce lactic acid but does not kill the spore-bearing bacilli, 1 
which produce butyric acid. The latter causes the formation of 
butyric acid from carbohydrates and fat and possibly from protein. 
Whether butyric acid is formed or not depends, according to Tob- 
ler, not on the kind of food present, but on the type of bacteria. 
This may be in part true, because fermentation cannot take place 
without fermentative organisms. On the other hand, however, 
the food components necessary for fermentation must be present 
in sufficient quantity to supply the bacteria with fermentable 
material. The lactic acid bacilli and the butyric acid bacilli are 
the only organisms which usually play a part in the various proc- 
esses of acid production in the stomach. The other bacteria (B. 
bifidus, B. acidophilus, B. coli and B. lactis aerogenes), which 
form acid are usually found only in the lower intestinal canal. 

BACTERIOLOGY OF THE UPPER PART OF THE SMALL INTESTINE 

The upper part of the small intestine, in comparison with the rest 
of the digestive canal, is relatively free from bacteria, both in the 
breast and in the bottle-fed infant. Hess 2 studied the bacteria 
of the duodenum during life by an ingeniously devised modifica- 
tion of his duodenal catheter. He found that in the new-born in- 
fants, who had received no food, the duodenum contained very 
few organisms, only from one to three growing on a plate. The 
organisms were staphylococci, Gram positive and Gram negative 
bacilli. Colon bacilli were not found. Infants in the first week of 
life also had very few bacteria in the duodenum and these were of 
the same varieties as those found soon after birth. There was 
more or less similarity between the bacteria of the stomach and the 
duodenum. The staphylococcus was the organism most frequently 
found at this age. Hess could not establish any relation between 
the amount of hydrochloric acid in the stomach, or of bile in the 
duodenum, and the number of bacteria. The presence or absence 
of icterus made no difference in the bacteriology of the duodenum 
in these babies. Cultures from the duodenal contents of older 
breast-fed babies showed from one hundred to two hundred col- 
onies per plate. The plate method would not be satisfactory for 

1 (Bodkin's butyric acid bacillus appears to be relatively rare and it is possi- 
ble that the gas-bacillus, which also forms butyric acid, is the one that is ordi- 
narily found.) 

2 Hess: Ergebnisse der inn. Med. u. Kinderh., 1914, xiii, p. 530. 



AND INFANT FEEDING 71 

an aerobic bacteria such as the bacillus bifidus, which may also be 
found in this region. It must be remembered, therefore, that these 
results may not represent the true condition. Those from bottle- 
fed infants showed many more. 1 

There is evidence that, while the duodenum may be practically 
free from bacteria during the intervals between digestion, there 
is a relatively large population in the small intestine while the food 
is passing through it. 2 According to Ficker 3 and Moro 4 the flora 
of the upper small intestine is composed principally of short Gram 
negative rods (colon bacillus and bacillus lactis aerogenes) with 
an occasional isolated bacillus bifidus communis, bacillus acido- 
philus and butyric acid bacillus, and enterococci. 

Under pathological conditions there may be an enormous in- 
crease in the bacteria in the small intestine. Prolonged fasts are 
regularly followed by an increase in the number of bacteria, 5 while 
all processes which cause an inflammation of the mucous mem- 
brane of the small intestine result in a diminution of its protective 
action against bacteria and a consequent increase in their numbers. 

Moro 6 believes that there can be an endogenous infection of 
the small intestine. Such an infection is probably present in most 
disturbances of nutrition, both acute and chronic. The epidemic 
of severe diarrhea, associated with the presence of inflammatory 
products in the stools (blood and pus), described by Escherich 7 
has been used as evidence for this point of view. The infants 
attacked were all young, their ages varying from four to ten 
months. The stools contained bacteria, which he called "blaue 
Bacillose" and which were proved to be, almost without question, 
"aciduric" 8 or acidophilic organisms. These organisms were 
probably identical with those which are normally present among 
the flora of the healthy nursling. Logan 9 on the other hand was 
unable to show that any colon-like organisms from cases with 
diarrhea showed any greater virulence to guinea pigs than the 
same organisms from babies not suffering from diarrhea. 

1 Moro; Jahrb. f. Kinderh., 1905, lxi, 870, may be consulted for the litera- 
ture. 

2 Moro: Arch. f. Kinderh., 1906, xliii, 340; Kohlbrugge: Cent. f. Bact. 
Orig. 1901, xxix, 571; Landsberger: Diss Konigsberg 1903, quoted by Kendall. 

3 Ficker: Arch. f. Hyg. 1905, liv. 354. 

4 Moro: Arch. f. Kinderh. 1906, xliii. 

5 Ficker: loc. cit. 

6 Moro: Miinchen. Gesellsch. f. Kinderh., 1907, xi, 15. 

7 Escherich: Jahrb. f . Kinderh., 1900, 52, 1. 

8 Kendall: Jour. Med. Research, 1911, xx, 117. 

9 Logan: Jour. Path, and Bact., 1914, xviii, 527. 



72 DISEASES OF NUTRITION 

BACTERIOLOGY OF THE LOWER PART OF THE SMALL INTESTINE AND 
OF THE LARGE INTESTINE 

There are relatively few bacteria in the small healthy intes- 
tine down to the lower part of the ileum. There they begin to 
increase in number so that when tfye large intestine is reached 
they are very numerous. The types of bacteria which are com- 
monly found, according to Kendall, are as follows: * The more 
commonly recognized bacteria are the B. bifidus (Tissier), the 
Mic. ovalis, the B. coli, the B. lactis aerogenes, and the B. acido- 
philus (Moro). These make up the normal nursling fecal flora. 
The B. lactis aerogenes appears in the upper levels of the tract, 
that is, the duodenum and jujunum; the Mic. ovalis in the lower 
jujunum and in the ileum to the ileocecal valve; the B. coli and 
the B. acidophilus in the region of the ileocecal valve, while the 
B. bifidus appears to dominate the ascending and transverse colon. 
This cannot be accepted without reservation since intestinal bac- 
teriology is by no means so simple as it would appear from the 
foregoing statement. The remainder of the tract to the anus is 
relatively poorly populated in relation to the ccecum so far as living 
bacteria are concerned. This is due in part to the considerable 
degree of dessication of the fecal contents of the intestines and in 
part to the accumulation of waste products, which appear to in- 
hibit the development of bacteria. 

The character of the bacteria in the large intestine depends 
largely upon the food, 2 and, since human milk is a relatively homo- 
geneous food, the tendency of the bacteriological flora of the breast- 
fed is toward uniformity. The bacteriological conditions in the 
artificially fed are, as would be expected, less consistent, because 
there is less uniformity in the food which they receive. The dis- 
tinctive features of the stools of the artificially fed are the relative 
•increase of Gram negative bacilli of the colon-aerogenes type and 
of cecal forms of the Mic. ovalis types. Coincidently, there is a 
decrease in the number of organisms of the B. bifidus type. The 
B. acidophilus is relatively more numerous and the B. bifidus less 
numerous. 

BACTERIOLOGY OF THE STOOLS 

The first stools (meconium), of the new-born are sterile, but 
they become infected shortly after birth. Within eighteen to 
twenty-four hours after birth, bacteria make their appearance 
in the stools and the meconium begins to disappear. The kinds 

1 Kendall: Jour. Med. Research, 1911-12, xx, 117. 

2 Moro : loc. cit. 



AND INFANT FEEDING 73 

and the number of bacteria which are found depend largely upon 
the season and the environment of the infant. 1 This is a period 
of mixed infection. The following organisms have been found 
in meconium: B. subtilis, B. coli, 2 B. bifidus, B. putrificus (Bien- 
stock), butyric acid bacillus, 3 and enterococci. 4 These organisms 
undoubtedly gain entrance to the intestinal canal through both the 
mouth and the anus. Meconium is a poor culture medium, prob- 
ably because of its small water content. 

The B. bifidus appears about the beginning of the third day and 
persists throughout the nursing period. It is an obligate anaerobe 
(Kendall), Gram positive, and is the most characteristic organism 
of the nursling's stool. It is apparently independent of the quality 
of the stool and is present in the classical golden-yellow, homo- 
geneous, pasty stool as well as in those which deviate from this 
character in consistency and color. 5 Although the B. bifidus dom- 
inates the typical field, other Gram positive bacteria can always 
be found. Other bacteria that have been described in the stools 
of the nursling are cocci, the B. lactis aerogenes, the B. coli, the 
B. acidophilus, butyric acid bacillus, the B. mesentericus and the 
B. aerogenes capsulatus (Welch). 

The bacteriology of the stools of the artificially-fed infant is 
much more complicated than that of the breast-fed. No charac- 
teristic type of bacteria predominates, but there is a mixture of 
bacterial types. Culturally, the same species are found as in the 
stools of the breast-fed infant. The general picture is, however, 
apt to be Gram negative in contradistinction to that of the stool 
of the breast-fed infant, which is usually Gram positive. The 
B. coli communis, and the B. lactis aerogenes are the most numer- 
ous of these predominating Gram negative bacteria. A peptoniz- 
ing bacillus, which is almost always absent from the stools of the 
breast-fed, has been recorded by Rodella. 6 Passini 7 found these 
types of butyric acid forming organisms, and isolated peptonizing 
organisms from the stools of apparently normal bottle-fed babies. 
The B. putrificus, the most typical example of a purely proteolytic 
organism, has been found in several cases. 

The discussion as to the causes which influence the appearance 

1 Kendall: Wisconsin Med. Jour., 1913, xii, No. 1. 

2 Escherich: loc. dt. 

3 Moro: Jahrb. f . Kinderh., 1905, lxi, 885. 

4 Sittler: Habititationsschr., Wurzburg, 1909, quoted by Tobler. 
6 Moro: Jahrb. f. Kinderh., 1905, lxi, 687. 

6 Rodella: Zeits. f. Hyg., 1902, xli, 466. 

7 Passini: Zeits. f. Hyg., 1905, xlix, 135. 



74 DISEASES OF NUTRITION 

and disappearance of certain bacteria is of more than polemic in- 
terest, since it may lead to some conclusions which will have a 
practical application. Kendall's x view is given as follows: "The 
intestinal tract is sterile at birth, because the uterine cavity is 
sterile/ ' The first infection takes place adventitiously. Any 
organisms which enter by the mouth or through the anus in the 
bath water, which can exist at body temperature, may find lodg- 
ment in the intestinal tract and may temporarily grow there. 
Many of the bacteria which thus succeed in entering the alimen- 
tary canal are spore-forming. During this period the food which 
is presented to them is largely detritus of fetal origin. At the 
beginning of the third day, when the breast milk has had a chance 
to thoroughly permeate the intestinal tract, new organisms appear, 
organisms which have a definite relationship to the type of food 
which is presented to them. It will be remembered that breast 
milk contains essentially 7% of lactose, about 3% of fat, and but 
13^2% of protein. Carbohydrate is, therefore, the dominant food. 
It is noteworthy that the organisms which appear in response 
to this diet are those whose metabolism is intimately associated 
with the utilization of sugar. These organisms thrive but poorly 
in a medium from which sugar is excluded. When other foods 
begin to replace the breast milk there is a definite change in the 
types of bacteria represented in the intestinal contents. The ob- 
ligate fermentative bacteria, such as the B. bifidus, are replaced 
by more plastic forms and by the B. coli which can accommodate 
their metabolism rapidly to dietary alterations. The B. coli for 
example can thrive equally well on a medium in which carbohy- 
drate is absent. It might appear from this rather definite altera- 
tion of types of bacteria in the intestinal tract following changes in 
the character of the food, that the food alone determined the 
intestinal flora. This may be somewhat influenced by the intes- 
tinal secretions. The essential feature, however, is the very direct 
relationship between the food and the bacterial response to it. This 
recognition of a relationship between food and bacteria in the intes- 
tinal tract is important in considering the intestinal flora, for it 
correlates the metabolism of the flora with the effects which it 
produces rather than attempting to establish indistinct relations 
between the morphology of the flora and these effects. These 
conclusions are supported by the work of Sittler, 2 and Bahrdt and 
Beifeld. 3 

1 Kendall: Wisconsin Med. Jour., 1913, xii, No.l. 

2 Sittler: Centralbl. f . Bakteriol, 1908, xlvii, 14 and 145. 

3 Bahrdt and Beifeld: Jahrb. f. Kinderh., 1910, lxxii, Erganzungsheft, 71. 






AND INFANT FEEDING 



75 



Further investigations are necessary to throw more light on the 
subject which is not as simple as it appears. It seems probable 
that other factors besides the sugar alone may play an important 
part in determining the intestinal flora, most important of which 
is the relation of the sugar to the other food components, especially 
those which favor putrefaction. 1 

It is interesting to note that Noguchi 2 in studying the growth 
and characteristics of the B. bifidus was able to transform it in 
the laboratory from the strictly anerobic type (B. bifidus, Tissier) 
to the facultative aerobic type (B. acidophilus, Moro) and back 
again to the anerobic type. Logan 3 believes that the B. bifidus 
of the breast-fed is replaced by the B. acidophilus in the bottle-fed. 

The Number of Bacteria in the Stools. — The most reliable 
figures as to the bacterial content of infant's stools are those ob- 
tained by Strassburger's method. 4 He found that the bacterial 
content of infant's stools was as follows: 

TABLE 16 



Age 


Food 


Digestion 


Per cent of bacteria in 
the dried stool 


2 months 
4^ " 
5 
2 
1 


cow's milk 
it a 

a a 

human milk 
it a 


normal 
tt 

? 

normal 

dyspeptic 


11.5 

42.3 
35.2 
25.8 
61.4 



Leschziner 5 found that 2% to 28.4% of the dried stool of the 
healthy breast-fed infant was composed of bacteria, while from 
6.52% to 29.4% of the total nitrogen was derived from bacteria. 
The newer and more perfect methods of Kramsztyk 6 and Klotz 7 
show that the number of fecal bacteria varies with the kind of 
food and that it is the chemical composition of the food rather 
than its bacterial content which is of significance. Escherich 8 
has shown that sterilization of the food has very little or no in- 



1 For a discussion of the action of the different sugars see Tobler. 

2 Noguchi: Jour. Exper. Med., 1910, xii, 182. 

3 Logan: Jour. Path, and Bact., 1914, xviii, 527. 

4 Strassburger: Zeits. f. klin. Med., 1902, xlvi, 413. 

5 Leschziner: Deutsch. aerzte Zeitung, 1903, No 17, 169. 

6 Kramsztyk: Zeits. f. Kinderh., 1911, i, 169. 

7 Klotz: Jahrb. f. Kinderh., 1911, lxxiii, 391. 

8 Escherich: Centralbl. f. Bacteriol., 1887, ii, 633 and 664. 



76 DISEASES OF NUTRITION 

fluence on the number of fecal bacteria. 1 Kramsztyk found the 
smallest number in the stools of infants fed on the breast. He 
found more in the stools of those fed on diluted cow's milk, and 
most in the stools of. those taking both human and cow's milk. 
Carbohydrates, especially in the form of malt extract, increase 
the number of bacteria. Klotz, whose figures are somewhat 
higher, found that the maximum amount of fecal bacteria in the 
dried feces is from 30% to 36 %. He also found the smallest 
numbers in soap stools. Strassburger, however, found that 60% 
of the dyspeptic stool was made up of bacteria. Although count- 
ing the number of living bacteria is attended with many dif- 
ficulties there can be but little doubt that a large proportion of 
the fecal bacteria are dead. 2 

Pathogenic Bacteria. — The typhoid bacillus and the various 
types of paratyphoid bacilli may be present in the stools of infants 
under the same conditions as in adults. The same is true of the 
tubercle bacillus and the cholera bacillus, as well as of other un- 
common microorganisms, such as the bacillus of anthrax. 

The various types of the dysentery bacillus are frequently 
found in the stools of infants. So also is the gas bacillus, as well 
as other closely allied microorganisms. When these organisms 
are found in considerable numbers in association with the symp- 
toms of disease of the intestinal tract, as in infectious diarrhea, 
they are, in most instances, the cause of the disease. This is also 
the case when large numbers of streptococci are found in associa- 
tion with fever and diarrhea. The presence of a few of these 
organisms in the stools in cases of diarrhea does not prove, how- 
ever, that they are the cause of the symptoms. They also ma; 
sometimes be found in small numbers in the normal stools of a 
parently healthy infants. Under these circumstances they 
to be regarded simply as saprophytes. 

1 For further literature consult Gerhard, Erg. d. Physiol. (Asber-Spiro 
1904, L. 107.) 

2 Eberle: Centralbl. f. Bacteriol., 1896, 19, 2. 




AND INFANT FEEDING 77 



CHAPTER VIII 
THE STOOLS IN INFANCY 

The examination of the stools is of the greatest aid in the diag- 
nosis of the nature of disturbances of digestion in infancy. It 
furnishes information which cannot be obtained so quickly and 
accurately in any other way. The clinical examination of the 
stools is, moreover, not a difficult matter. It requires but little 
time and but little apparatus. The methods are simple and easy 
to learn. It is fortunately not necessary to make use of the more 
complicated methods of analysis in every-day work, because the 
simple methods of clinical examination give information which 
is as useful for practical purposes as that furnished by the more 
accurate and elaborate procedures. 

The character of the stools depends primarily on the composi- 
tion of the food. It is modified by the digestive powers of the 
individual infant and by the amount and rapidity of absorption 
of the products of digestion. The amount of absorption depends 
to a considerable extent on the rapidity with which the intestinal 
contents pass through the intestinal tract. The character of the 
stools also depends on the nature of the bacterial flora of the in- 
testine. This is dependent, to a large extent, on the nature of the 
food. The influence which the bacteria exert depends largely on 
the digestive power of the infant and the rapidity with which the 
products of digestion are absorbed. The more feeble the digestive 
power and the slower the absorption, the greater the effect of the 
bacteria. It is often difficult, therefore, to draw conclusions from 
the examination of the stools as to just what is going on in the 
intestines. It is usually possible, however, to determine whether 
any given food element is properly digested and assimilated or 
not, and in many diseased conditions to tell what element is at 
fault. The presence of an improperly digested food element in 
the stools does not necessarily show, however, that this is the 
element primarily at fault, although it usually is. Fat curds may, 
for example, be present in the stools as the result of the fermenta- 
tion of sugar, the excessive peristalsis resulting from the irritation 
caused by the products of the fermentation of sugar preventing 
the proper absorption of the fat. When the element at fault is 



78 DISEASES OF NUTRITION 

known, it can be reduced and the necessary amount of the reduc- 
tion determined by repeated examination of the stools. 

MECONIUM 

The meconium is dark brownish-green in color. The first 
meconium passed is semi-solid, having been partially dried out 
in the large intestine. The remainder is more viscid. It is com- 
posed of mucus, bile, intestinal secretions and cells, with vernix 
caseosa, epithelial cells and hairs swallowed with the amniotic 
fluid. The meconium stools are replaced after from two to 
four days by stools composed of bile-tinged mucoid intestinal 
secretions. They are usually dark-green, but may be dark-brown 
or brownish-yellow, according to whether the bile pigment is 
in the form of bilirubin or biliverdin. The change to the normal 
fecal stool occurs gradually during the next two or three days. 

The stools of the breast-fed infant differ normally in their char- 
acteristics from those of the infant fed on cow's milk. The addi- 
tion of starch to cow's milk changes the character of the stools. 
The appearance of the stools varies also with the kind of sugar 
which is added to the milk. 

THE STOOLS OF BREAST-FED INFANTS 

During the first few weeks or months of life, the breast-fed infant 
has three or four stools daily. These are of about the consistency of 
pea soup and of a peculiar golden-yellow color. The odor is slightly 
sour or aromatic, and the reaction slightly acid. The number of 
stools gradually diminishes to two or three in the twenty-four hours 
and the consistency becomes more salve-like. The other character- 
istics are the same. The golden-yellow color is due to bilirubin, 
which, on account of the short time which it remains in the intes- 
tine, the relatively low protein content of the milk and the low re- 
ducing power of the infant's intestine, passes unchanged through 
the intestinal tract. The odor is due to a combination of lactic and 
fatty acids. The acid reaction is due to the relative excess or fat 
over protein in the milk. 

It is not uncommon for babies, even when they are thriving on 
the breast, to have a large number of stools of diminished con- 
sistency and of a brownish color. The examination of the breast- 
milk in such instances usually shows that the proteins are high. 
It is also not unusual to find many soft, fine curds, and some- 
times mucus in the stools of healthy breast-fed babies. Such 



AND INFANT FEEDING 79 

stools are undoubtedly abnormal. It is unwise to pay too much 
attention to them, however, if the baby is gaining in weight and 
appears well. The breast-fed infant will often go weeks or months 
without a normal stool and yet thrive perfectly, while if a baby 
had such stools when it was taking cow's milk it would not thrive 
and would show distinct evidences of malnutrition. It is, there- 
fore, not only unnecessary, but distinctly wrong, to wean a baby 
simply because the stools are abnormal, if it is doing well in other 
ways. 



Infants that are thriving on cow's milk mixtures have, as a gen- 
eral rule, fewer movements in the twenty-four hours than do breast- 
fed babies, and these movements are firmer in consistency. Slight 
constipation is not uncommon after the first few months and is not 
pathological. The color of the stools is a lighter yellow. This is 
probably due in part to the relatively larger amount of protein and 
in part to the fact that some of the bilirubin is converted into hydro- 
bilirubin. When the relative proportions of fat and protein in the 
mixtures are approximately the same as they are in breast milk 
the odor and reaction of the stools are essentially the same as when 
the baby is taking breast milk. When infants are given whole 
cow's milk or simple dilutions of cow's milk, so that the percentage 
of protein is about the same as that of the fat, the odor is slightly 
modified toward the fecal or cheesy, because of the action of bac- 
teria on the casein. The reaction becomes alkaline for the same 
reason. 

Skimmed Milk Mixtures. — When infants are fed on skimmed 
milk or on mixtures containing very small percentages of fat and 
high percentages of protein, the stools have a slightly brownish- 
yellow color, a slightly cheesy or foul odor and a strongly alkaline 
reaction, because of the longer stay of the casein in the intestine 
and the consequently greater opportunity for bacterial action and 
for the change of bilirubin into hydrobilirubin. In most instances 
the stools have, when spread out, a peculiar, smooth, salve-like 
appearance like those from buttermilk. 

Whey and Whey Mixtures. — When infants are fed on whey 
to whey mixtures low in fat, the stools have essentially the same 
characteristics as those from skimmed milk, except that they are 
usually browner. Whey has a laxative action in many instances 
and sometimes has to be given up on this account. 

Starch Mixtures. — When starch is added to cow's milk mix- 
tures the color of the stools becomes more distinctly brownish and 



80 DISEASES OF NUTRITION 

the reaction tends toward the acid. The odor is more aromatic. 
The source from which the starch is derived apparently has but 
little effect on the number of stools, although it is commonly 
thought that barley starch is constipating and oatmeal starch 
laxative. The action, if there is any, seems to vary with the in- 
dividual infant. It must not be forgotten in this connection that 
most starch flours contain small brownish specks which are the 
remains* of the husks (cellulose). These specks pass through the 
gastrointestinal tract unaffected and appear in the stools. They 
are sometimes mistaken for intestinal sand or for dirt. 

Dextrin-Maltose Mixtures. — The addition of the various 
combinations of the dextrins and maltose to cow's milk mixtures 
changes the color of the stools to a distinct brown, tends to make 
the reaction acid and to increase the acidity of the odor. These 
sugars usually have a laxative influence but sometimes constipate. 
In general, the higher the proportion of maltose, the greater is the 
laxative action. When these combinations of the dextrins and 
maltose, or the malted foods, which amount to the same thing, 
are given without milk, the stools are dark-brown, sticky, acrid 
in odor and acid in reaction. 

Buttermilk and Buttermilk Mixtures. — The stools of infants 
fed on buttermilk and buttermilk mixtures are of a peculiar 
shiny, salve-like appearance, grayish-brown or olive-green in 
color, alkaline in reaction and have a very characteristic acrid 
odor. 

Animal Food. — When beef juice or broth is added to the 
infant's diet the color of the stools is changed to brown, while the 
odor becomes fecal and the reaction alkaline from the action of 
bacteria on the proteins. It is not uncommon when babies are 
taking beef juice to have one portion of the stool brown with 
the remainder yellow, the dividing line between the two colors 
being very distinct. The dark color represents, of course, the meal 
at which the beef juice was taken. 

THE STARVATION STOOL 

The starvation stool is composed of bile, the intestinal secre- 
tions and bacteria. It resembles the meconium in appearance. 
It is small, and brownish or brownish-green in color. It is some- 
times constipated, sometimes loose. It usually has a stale odor 
like that of starch or paste. In some cases it has the odor of 
acetic acid as the result of action of microorganisms. It not in- 
frequently contains bile-stained mucus. 






AND INFANT FEEDING 81 

REACTION OF THE STOOLS 

The reaction of the normal stool depends on the relation be- 
tween the fat and protein in the food. When there is a relative 
excess of fat the reaction is acid; when there is a relative excess 
of protein the reaction is alkaline, the reaction depending, in the 
one case, on the products of the decomposition of fat, in the 
other on the products of the decomposition of protein. The 
carbohydrates have but little effect on the reaction of the normal 
stool. When the carbohydrates are in excess, or when there is 
fermentation of the carbohydrates as the result of bacterial action, 
the acidity of the stools is markedly increased. Stools which irri- 
tate the buttocks are invariably acid in reaction and in many in- 
stances this excessive acidity is due to the fermentation of carbohy- 
drates. Frothy stools are usually acid in reaction and the result 
of the fermentation of carbohydrates. Sometimes, however, the 
frothiness is caused by gases formed during the decomposition of 
protein. The reaction of the stools is best tested by placing wet 
red or blue litmus paper on a fresh surface of the stool. It is, how- 
ever, except when there is excessive acidity, of comparatively 
little importance clinically. 

ODOR OF THE STOOLS 

The odor of the stools depends on the composition of the food, 
the rapidity of the absorption of the products of digestion and the 
degree of the bacterial activity. The fats give the odor of butyric 
or lactic acid to the stools. The carbohydrates, if thoroughly 
utilized, do not affect the odor; if not utilized, they give the odors 
of lactic, acetic or succinic acids. The proteins give cheesy odors 
of various sorts, sometimes those of skatol, indol and phenol. 

The odor of the normal stool and the influence of variations 
in the diet upon it have already been mentioned. The stools of 
fat indigestion may have a strong odor of butyric acid, those of 
protein indigestion various cheesy or putrefactive odors as the 
result of the decomposition of the protein by bacteria. When 
several elements of the food are improperly digested the odor is a 
combination of those resulting from the decomposition of the va- 
rious elements. The stools of cholera infantum are almost odorless. 
Stools composed almost entirely of mucus have a peculiar aromatic 
odor resembling that of wet hay. When there are deep ulcerative 
or gangrenous processes in the intestine, the stools have a putrefac- 
tive or gangrenous odor. 



82 DISEASES OF NUTRITION 



COLOR OF THE STOOLS 



The normal variations in the color of the stools according to 
the composition of the food have already been mentioned. Ab- 
normalities in the color are very common. The color of the stool 
must not be judged from the outside, as it may change very 
rapidly as the result of drying and exposure to the air. The 
stool must be broken up or smoothed out and the inside examined. 

Green. — The most common abnormal color is green. The 
shade of green may vary from a very delicate light grass-green to 
a dark spinach-green. In a general way, the darker the green, the 
greater its significance. When a stool is otherwise normal, a very 
light grass-green color is of no practical importance. The change 
from yellow to green after the stool is passed is not abnormal. 
The green color is, in the vast majority of instances, due to the 
change of bilirubin to biliverdin. There is much doubt as to the 
cause of this change. It is probable that it may be due to either 
excessive acidity or alkalinity of the intestinal contents or to the 
presence of some oxidizing ferment. The green color is not charac- 
teristic of any special type of disease. In some instances it is due 
to the action of the bacillus pyocyaneus. If it is due to bacterial 
action, the addition of nitric acid decolorizes the stool. If it is due 
to biliverdin, the addition of nitric acid gives the characteristic 
colors of Gmelin's test. 

Gray. — The next most common abnormal color is gray. This 
is due, as a rule, to the absence of bile and the presence of some 
form of fat, usually soap, in the stool. It must be remembered, 
however, that there may be bile in the stool even when it is gray, 
the bile pigment being in the form of the colorless leucohydrobili- 
rubin. It is never safe, therefore, to conclude that there is no bile 
in the stool without a chemical examination. The easiest and most 
satisfactory test is that with corrosive sublimate. This test is, 
however, not always accurate. When the stools are gray at birth 
or become so within a few days after birth, the lesion is usually a 
congenital obliteration of the bile ducts. It may be, however, an 
atresia of, or an obstruction in, the intestine. When the gray color 
appears later, and especially when it is associated with the pres- 
ence of large amounts of mucus, the trouble is usually in the 
duodenum. 

White. — White stools are due to the presence of undigested 
fat in the form of soaps. The white stools may be soft, looking like 
curdled milk or, more often, hard and dry, resembling the stools of 
a dog which has been eating bones. 



AND INFANT FEEDING 83 

Black. — The black stool, while in rare instances due to the 
presence of changed blood, is usually due to the action of some 
drug. This drug is ordinarily bismuth, but sometimes iron or 
charcoal. In this connection it is well to remember that, when 
there is no sulphureted hydrogen in the intestine, bismuth may 
pass through the intestinal tract without being changed in color. 
The administration of a grain or two of sulphur in the twenty- 
four hours will turn the stools black. Whether this is of any ad- 
vantage or not is questionable. 

Blue. — The stools are sometimes of a slaty-blue color. This 
color is due to some change in the bile pigments and is of no more 
significance than the green color. 

Pink. — It is very common to see a pink stain on the diapers 
about a stool which is otherwise normal or nearly so. This pink 
stain is of no especial significance and is due to some unknown 
change in the bile pigment. 

ABNORMAL CONSTITUENTS 

Curds. — The most common abnormal constituents of the stools 
are curds. There are two kinds of curds, one primarily composed of 
casein, the other composed mainly of fat, mostly in the form of 
fatty acids and soaps. The small amount of fat in the casein 
curds and the small amount of protein in the fat curds are merely 
incidents. The casein curds vary in size from that of a bean to 
that of a pecan nut. They are usually white, sometimes yellow in 
color. They are firm and tough, cannot be broken up by pressure, 
and sink in water. When placed in formalin they become as hard 
as rocks. They are insoluble in ether. The fat curds are small, 
varying in size from that of a pinhead to that of a small pea. They 
vary in color from white to yellow or green, according to the general 
color of the movement. They are easily broken up by pressure and 
when shaken up in water tend to remain in suspension. They are 
soluble in ether to a considerable extent after acidification and 
heating, and are unaffected by formalin. 

Mucus. — Mucus can be detected in small amounts under the 
microscope in the majority of normal stools and is almost invari- 
ably present in abnormal stools. It is never present macroscopic- 
ally in normal stools, but is very often visible in the abnormal. 
It does not denote any special form of disease, but merely an ex- 
cessive secretion of the mucous glands of the intestine as the result 
of some irritation. When it is thoroughly mixed with the feces 
it usually comes from the small intestine; when in combination 



84 DISEASES OF NUTRITION 

with a clay-colored stool, from the duodenum; when on the out- 
side of a constipated stool, from the rectum. Stools composed 
mostly or entirely of mucus and blood indicate either severe in- 
flammation of the colon or intussusception. Undigested starch is 
often mistaken for mucus. It can be distinguished by the addi- 
tion of some preparation of iodine, which stains starch blue but 
does not affect the mucus. The suspected material should be 
taken off of the diaper in order to avoid possible confusion because 
of the presence of starch on the diaper. It is of importance not to 
use too strong a solution of iodine. 

Blood. — Blood on the outside of a constipated stool indicates 
a crack of the anus. Blood mixed with mucus indicates either 
severe inflammation of the large intestine or intussusception. 
Blood in infancy is seldom due to hemorrhoids. In rare instances 
the hemorrhage may come from an intestinal polyp. Hemorrhage 
from the bowel in the first few days of life is ordinarily a symptom 
of hemorrhagic disease of the new-born. 

Pus. — Pus indicates severe inflammation of the large intestine. 
It is usually not present early in the disease, but appears later. 
When the infants survive the acute stage it persists into convales- 
cence. Pus can be found with the microscope in nearly every case 
of inflammation of the colon, but is of no special significance unless 
visible macroscopically. 

Membrane. — Membrane indicates very severe inflammation of 
the large intestine and is rarely seen, the patients usually dying 
before membrane appears in the stools. 

Other abnormal constituents are undigested masses of food, 
foreign bodies which have been swallowed, and worms. 

MICROSCOPIC EXAMINATION OF THE STOOLS 

The macroscopic examination of the stools affords data suffi- 
ciently reliable for clinical work in the great majority of instances. 
It may, however, lead to erroneous conclusions, especially with 
regard to the amount of fat and undigested starch. Fatty and 
starchy stools sometimes appear perfectly normal macroscopically, 
and microscopic examination will alone prevent mistakes. It is 
advisable, therefore, in all but the plainest cases, to examine the 
stools microscopically as well as macroscopically. The microscopic 
examination of the stools is not a difficult procedure, and can be 
carried out in ten minutes or less by anyone accustomed to it. Con- 
trols of the microscopic examination by chemical examination of 
the stools have shown that it gives results sufficiently reliable for 



AND INFANT FEEDING 85 

clinical purposes. A certain amount of experience is necessary, 
however, in order to recognize the variations in the microscopic 
picture. The stools normally show a certain amount of fat in some 
form or other, but never show undigested starch. The chief diffi- 
culty in the microscopic examination is to learn to recognize the 
normal variations in the amount of fat. 

The feces, if hard, are first rubbed up with a little water. It is 
important not to dilute them too much. If not hard, they are 
thoroughly mixed. A small portion is then spread out very thin 
on a slide under a cover-glass and examined for the presence of 
undigested tissues or pathological elements, such as blood, pus 
and eggs of parasites. 

The second portion is stained with LugoPs solution (iodine 2, 
potassium iodide 4, distilled water 100) and examined for starch. 
The starch granules stain blue or violet. Certain microbes also 
stain blue. These, the so-called iodophilic bacteria, are associated 
with faulty carbohydrate digestion, and, when found alone without 
other symptoms, are suggestive of a beginning disturbance in the 
digestion of the carbohydrates. Before concluding that undigested 
starch is present, all possibility of contamination with baby pow- 
ders must be eliminated. A diagnosis of starch indigestion should 
never be made unless the characteristic form of the starch granules 
is made out. 

A third portion, undiluted with water, is stained with a saturated 
alcoholic solution of Sudan III. The neutral fat drops and fatty 
acid crystals stain red. Soap crystals do not stain with Sudan III. 
After this specimen is examined and the microscopic picture is 
clear, a drop of glacial acetic acid is allowed to run under the cover- 
glass, is thoroughly mixed in, and then heated until it begins to 
simmer. It should not be boiled, because, if it is, the fat is likely 
to be driven to the edge of the cover-glass and lost. This pro- 
cedure converts the soap into neutral fat and fatty acids which 
appear as large stained drops. They crystallize upon cooling. 
They usually retain the red stain. Any increase in the amount 
of fat after the addition of acetic acid indicates the presence of a 
corresponding amount of soaps. 

This method of staining, while it enables us to distinguish between 
the amount of neutral fat and fatty acids together, on the one 
hand, and of soaps, on the other hand, does not make it possible 
to determine how much of the fat is in the form of neutral fat. 
This point can be determined by the use of carbol-fuchsin. The 
stain may be prepared as it is for staining tubercle bacilli. This 
may be too strong, however, and, if so, the solution should be 



86 



DISEASES OF NUTRITION 



diluted with an equal amount of 95% alcohol. Carbol-fuchsin does 
not stain neutral fat, but stains fatty acids a brilliant red and soaps 
a dull red. The following table shows the difference in the stain- 
ing properties of neutral fat, fatty acids and soaps. 

TABLE 17 



Stain 


Neutral fat 


Fatty acids 


Soaps 


Sudan III 

Diluted carbol- 
fuchsin 


Drops staining 
orange red 

Drops do not 
stain 


Drops staining red, 
or crystals stain- 
ing orange-red 

Drops and crystals 
stain brilliant red 


Crystals do not 
stain 

Crystals stain dull 
red 



It is possible, therefore, by using these two stains in conjunction, 
to determine accurately enough for clinical purposes the relative 
proportions of neutral fat, fatty acids and soaps in the stool. An 
excess of neutral fat indicates that the digestion of fat is not carried 
on normally; an excess of fatty acids and soaps, that the digestion 
is normal but absorption is abnormal. It must be remembered in 
interpreting the importance of an excess of fat in the stool, that 
the younger the baby, the less is the significance of an excess of fat 
and vice versa. 

It is well to examine the specimen first with a low-power objec- 
tive and later with a high-power in order to bring out the detailed 
structure. 

THE BACTERIOLOGIC EXAMINATION OF THE STOOLS 

Our knowledge of the bacteriology of the disturbances of diges- 
tion and of the various inflammatory diseases of the intestine is so 
limited at present that no conclusion of clinical importance can be 
drawn from the microscopic examination of the stools, the only ex- 
ception being possibly the presence of large numbers of iodophilic 
bacteria, which, as already stated, point to disturbance of the 
digestion of the carbohydrates. In general, Gram-positive bacteria 
will predominate in an acid and Gram-negative in an alkaline 
stool. The determining factors are the same as those which cause 
the reaction of the stool. 



STOOLS OF DIFFERENT TYPES OF INDIGESTION 

The characteristics of the stools in some of the more marked 

types of indigestion are fairly definite. They are summarized below. 

The Stools of Fat Indigestion. — Undigested fat may show it- 



AND INFANT FEEDING 87 

self in the stools in the form of small, soft curds, by giving a greasy, 
shiny appearance to the stool or by giving it a gray or white color. 
The small curds are, of course, easily recognized. Sometimes the 
stools have an oily appearance and the color is that of Indian meal. 
The presence of undigested fat may be shown roughly by rubbing 
some of the stool on a piece of smooth, soft paper. If there is an 
excess of fat, the paper will have, when dry, the appearance of 
oiled paper. When there is an excess of neutral fat, the stools are 
often of a creamy consistency. If the fat is largely in the form of 
soaps, the stools are usually clay-colored or very dry and crumbly. 
The reaction is highly acid. The odor is rancid, like that of 
butyric acid. Microscopically, these stools show a large excess of 
fat in various forms. 

The Stools of Carbohydrate Indigestion. — The character of 
the stools of carbohydrate indigestion depends on whether the 
disturbance is in the digestion of starch alone without bacterial 
action or in the digestion of either or both starch and sugar with 
bacterial fermentation. When the disturbance is solely in the 
digestion of starch and the bacterial fermentation is not marked, 
the stools are brown or golden-yellow in color and salve-like in 
consistency. They may, as already stated, appear macroscopically 
normal. In rare instances they are very dry and brittle. The 
reaction is acid. The odor is acid, the character of the odor depend- 
ing on the form of acid present. The iodine test will often show the 
presence of undigested starch macroscopically. Microscopically 
these stools show undigested starch by the iodine test, and an 
excess of iodophilic bacteria. 

When bacterial fermentation is added to the disturbance of 
digestion of either starch or sugar, the stools are loose, green and 
frothy. The reaction is acid from the presence of lactic, acetic or 
succinic acid. The odor is acid, the character of the odor depend- 
ing on the form of acid present. These stools often cause excoria- 
tion of the buttocks and genitals. 

The Stools of Protein Indigestion. — The presence of large, 
tough curds in the stools is, of course, evidence of protein or rather 
casein indigestion. In general, however, the stools of protein 
indigestion are loose, brownish in color, alkaline in reaction and 
with a foul odor, the odor in some instances being fecal, in others 
cheesy, in others a combination of the two. 

Mixed Forms of Indigestion. — Mixed types of stools as the 
result of mixed types of indigestion modified by bacterial fermenta- 
tion and decomposition are far more common than the pure types 
alone and are often very difficult to interpret. 



88 DISEASES OF NUTRITION AND INFANT FEEDING 

The examination of the stools gives information regarding the 
digestive processes which cannot be obtained in any other way. 
Without such examination the treatment of disturbances of diges- 
tion is always unscientific and often irrational. The macroscopic 
examination of the stools affords information of the greatest 
importance, but in many instances will lead to error unless the 
microscopic examination is also made. The microscopic examina- 
tion is a simple one and requires but little time. The results ob- 
tained from it are, for practical purposes, as reliable as those 
obtained from the chemical examination. The stools should be 
examined both macroscopically and microscopically in every 
disturbance of the digestion in infancy. 






SECTION II 
BREAST FEEDING 

CHAPTER IX 
GENERAL CONSIDERATIONS 

It is generally recognized that the natural food for the human 
infant is human milk, that breast-fed babies are more likely to live 
than the artificially-fed and that, as a class, they are healthier, 
more vigorous and more resistant. Few appreciate, however, how 
much greater the mortality is in the artificially-fed than in the 
breast-fed. There are many statistics to prove this fact. It is 
hardly necessary, however, to give more than a few of them. 

Mortality. — In Berlin, where the character of the feeding of 
all living children is determined by the census, during the five 
years, 1900 to 1904, only 9% of the infantile deaths were in breast- 
fed babies. 1 The Department of Health of New York City esti- 
mates that over 85% of all infantile deaths are in those artificially 
fed. 2 Davis 3 found that in Boston, in 1911, 74% of the deaths of 
infants over two weeks of age were in the artificially-fed, and 
calculates that in Boston the bottle-fed is six times as likely to die 
as the breast-fed infant. Luling, 4 in a study of 13,952 children 
born in Baudeloque's clinic, found an infant mortality of 14% in 
the breast-fed, 31% in those who were bottle-fed by their own 
mothers, and 50% in those who were bottle-fed by strangers. 
Armstrong, 5 in a study of 1,000 infants in Liverpool, in 1903, 
found that 8.4% of the breast-fed babies died in the first year 
against 22.8% of the artificially-fed. Of 1,000 fatal cases of 
diarrheal disease investigated by the Health Department of the 
City of New York, in 1908, only 90 had previously been entirely 
breast-fed. 2 Further evidence of the effect of breast feeding on the 

1 Graham: Journal A. M. A., 1908, li, 1045. 

2 Holt: Journal A. M. A., 1910, liv, 682. 

* Davis: Amer. Jour. Diseases of Children, 1913, v, 234. 

4 Luling: These de Paris, 1900. 

6 Armstrong: British Jour. Children's Diseases, 1904, i, 115. 



90 DISEASES OF NUTRITION 

infant mortality is the fact that during the Siege of Paris, 1870-71, 
while the general mortality rate doubled, the infant mortality rate 
fell from 330 to 170 per thousand deaths, the reason being that the 
women, having no other food to give their babies, had to nurse 
them. 1 

Relative Frequency of Breast Feeding. — The relative frequency 
of breast feeding varies in different countries and in different 
races. In Japan, breast feeding is the rule. In Greenland, and 
among the Eskimos, artificial feeding is practically unknown. The 
proportion of breast-fed babies is much smaller in other countries. 
Nordheim, 2 for example, found, as the other extreme, that only 
3.6% of 1,000 women coming to the Women's Dispensary in 
Munich, nursed their babies longer than three months. Davis, 3 
from an investigation made in 1911, estimated that 68% of all 
Boston babies between the ages of two weeks and one year were 
breast-fed, while the Board of Health of the City of New York 
estimates that about 85% of the infants in New York are breast- 
fed. 4 Holt, 4 however, thinks that, as these data were gathered 
largely from the tenement district statistics, they are too high, 
and that 80% is nearer the truth for the entire population. 
Koplik 5 found that 10% of 1,007 infants, seen in private practice 
in New York City, were exclusively breast-fed, 30% exclusively 
bottle-fed and 60% breast and bottle-fed. Forty per cent of 
these were weaned before the fourth month. 

Ability of Women to Nurse Their Babies. — There are two rea- 
sons why women do not nurse their babies. They are either unable 
or unwilling. There is much difference of opinion as to what 
proportion of women are really able to nurse their babies, although 
it is generally conceded that a large proportion of those who do not 
nurse their babies could nurse them, if they thought they could or 
were compelled to do so. Nordheim 2 found that of 1,000 women 
642 had never nursed, and that 86.7% of these had no good reason 
for not nursing. Dluski 6 found that 99% of the women in the 
Maternity Department of Professor Pinard, in Paris, were able to 
nurse their babies. Holt 4 estimates, however, that not over 25% 
of the well-to-do and cultured women of New York City are able 
to nurse their babies over three months. 

1 Brehmer: Wochenschr. f. Sauglingsfiirsorge., 1907, 209. 

2 Nordheim: Archiv. f. Kinderheilk., 1901, xxxi, 89. 

3 Davis: Amer. Jour. Diseases of Children, 1913, v, 234. 

4 Holt: Journal A. M. A., 1908, li, 1045. 

5 Koplik: Journal A. M. A., 1912, lviii, 75. 

6 Dluski: These de Paris, 1894. 



AND INFANT FEEDING 91 

There is no doubt that a far larger proportion of women can 
nurse their babies than was formerly supposed. Martin x found 
that in Wurtemberg, where formerly only 41% of the women in the 
clinics nursed their babies, 100% are now capable. Constant 
instruction at the Consultations des Nourrissons, in France, has 
increased the number of cases of maternal feeding among the 
poor by 20% or 30%. The experience at similar institutions in this 
country has been the same. There is a general belief, moreover, 
although there are no figures to prove it, that the ability of women 
in the wealthier and more highly educated classes in this country 
to nurse is steadily increasing. 

Unwillingness to Nurse. — The main reason why women do 
not nurse their babies is that they do not appreciate its importance. 
This is due to a considerable extent to the fact that they do not 
receive proper advice from doctors, nurses and midwives, who, 
unfortunately, are themselves in many instances ignorant of the 
importance of breast feeding. The unwillingness to nurse among 
the wealthier and fashionable classes is in part because they are 
unwilling to sacrifice their own pleasure and convenience, in part 
because it is not fashionable in certain circles to nurse, and in part 
because of the opposition of their husbands, who do not wish to be 
deprived of their wives' society. Many of them feel, moreover, 
that on account of the great improvement in artificial feeding, 
their babies will do well enough, even if they do not nurse them. 
The unwillingness of women among the poorer classes to nurse 
their babies is, in many instances, due to the fact that on account 
of poverty they are obliged to go to work. Ignorance of the 
advantage of breast feeding plays a greater part in their unwilling- 
ness to nurse than among the better educated, as do also the 
advertisements of proprietary foods. 

Contraindications to Breast Feeding. — A woman with active 
pulmonary tuberculosis should not nurse her baby, because of the 
great danger of infection of the baby. It is usually inadvisable 
for a woman with healed tuberculosis, pulmonary or otherwise, or 
with closed tuberculosis, to nurse her baby, because of the danger of 
starting up or increasing the activity of the process. Although 
tubercle bacilli are sometimes present in the milk of tuberculous 
women, the danger of infection from this cause is negligible. 
Syphilis is not a contraindication to nursing because, if the mother 
has active syphilis the baby has been infected before birth, and if 
the baby has syphilis, the mother always has it. Insanity is a 
contraindication to nursing as is, in most instances, epilepsy. Very 
1 Martin: Archiv. f. Gyn., 1905, lxxiv, 513. 






92 DISEASES OF NUTRITION 

delicate or feeble women and women suffering from serious chronic 
diseases should not nurse their babies, partly because their milk is 
usually of poor quality, and partly because the strain of nursing 
is certain to do them serious harm. It is usually inadvisable for 
women that have had severe hemorrhages, who are septic or who 
have nephritis to nurse their babies. Women suffering from puer- 
pural eclampsia should not nurse their babies, because of the danger 
of the production of serious or even fatal symptoms in the babies, 
which are probably manifestations of anaphylaxis. Women who 
have been unable to nurse previous children satisfactorily can 
hardly be expected to nurse. It is wiser, however, for them to 
make the attempt because they are sometimes able to do it, al- 
though unsuccessful in the past. 

A certain number of infants are unable to nurse because of 
deformities of the lips and mouth. Premature infants are often too 
weak to nurse, as are some congenitally feeble babies. Such babies 
should not, however, be deprived of the advantages of human milk. 
The milk should be pressed from the breast, or drawn with a 
breast pump and fed to the baby with a dropper, spoon or Breck 
feeder, or through a tube. 









AND INFANT FEEDING 



CHAPTER X 
HUMAN MILK. CHEMISTRY AND BIOLOGY 

The Breast Glands. — Glands which secrete milk are present, as 
a rule, in the female mammal only during and after pregnancy. A 
few drops of milk may be squeezed from the breasts before parturi- 
tion, but, generally speaking, milk is present in them only after 
delivery. 

According to Czerny and Keller x if the infant does not empty the 
breasts and they fill up again with secretion, there is a change in the 
composition of the milk as the result of the absorption of its dif- 
ferent components. It is, therefore, necessary to differentiate 
between the milk of women whose breasts are regulated and 
sufficiently emptied during nursing and that of women whose 
breasts are not sufficiently emptied. In the first there is no absorp- 
tion of the milk components in the glands, while in the latter the 
chemical composition is more or less changed by absorption. They 
designate the latter as colostrum. Under this term they include all 
milk in which there has been any absorption; not only the milk in 
the breasts during pregnancy and the first few days postpartum, 
but also the milk when the secretion is in the process of drying up. 

Colostrum. — All authors agree that the milk excreted during the 
first few days postpartum differs essentially from that after lacta- 
tion is well established. It is of a deep lemon-yellow color. This 
color is present only during the first few days postpartum and is 
never seen at any later stage of lactation. Czerny (p. 408) believes, 
on the basis of his own work, that this color is due to a coloring 
matter contained in the fat drops. The colostrum is not as sweet 
as the later milk. It is coagulated into solid masses by heat. 
This depends, according to Tiemann, 2 on the presence of a globulin, 
which coagulates at 72 C. (161.6 F.). The amount of cholesterin 
and lecithin is greater than in milk. 3 The fat in colostrum contains 
less of the volatile fatty acids than does normal milk. 4 

Czerny and Keller: Des Kindes Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wien, 1906, i, 407. 
2 Tiemann: Ztschr. f. Physiol. Chem., 1898, xxv, 363. 

3 Voltz: Oppenheimer's Handbuch der Biochemie, Jena, 1910, iii, I, 382. 
4 Nilson: Maly's Jahresb., 1891, xxi, 142. 



94 



DISEASES OF NUTRITION 



It is obvious that only those analyses of colostrum which have 
been made during the first days postpartum are of any value, as 
later it is mixed with milk. The specific gravity of colostrum ranges 
from 1.028 to 1.072, the average being about 1.040. x It has a 
strongly alkaline reaction. 

J. Konig 2 gives the following percentages as the average of five 
analyses of early human colostrum: Water, 86.4; nitrogenous sub- 
stances, 3.07; fat, 3.34; lactose, 5.27; salts, 0.40. 

TABLE 18 

Composition of Colostrum as Determined by Various Investigators 
(czerny and keller) 



Author 


Day, post- 
partum 


Fat, 
per cent. 


Lactose, 
per cent. 


Protein, 
per cent. 


Nitrogen, 
per cent. 


Ash, 
per cent. 


Solids, 
per cent. 


Pf eiffer 3 


1 

2 

2 
j 26-51 * 
I 56-61 * f 
? 26-48 * 
I 48-69 * t 


2.59 
2.17 
3.77 
4.08 
3.92 
1.67 
2.02 


2.76 
3.50 
5.39 
4.09 
5.48 
5.20 
5.08 


9.75 
7.45 
3.31 


0.928 
0.508 
0.336 
0.226 


0.408 

0.340 

0.27 

0.48 

0.41 

0.36 

0.40 




Pf eiffer 




V. & J. Adriance 4 . 

Camerer and Sold- 

ner 5 


12.78 
16.04 
14.12 
10.32 
10.12 


* Hours. f ! 


Same womai 


i. 













Pfeiffer, 3 found that the nitrogenous substances in human milk 
were as follows: First day, 8.6%; third to seventh day, 3.4%; 
during second week, 2.28%; in second month, 1.84%; in seventh 
month, 1.52%. The amount of sugar increases as the protein in 
human milk diminishes. The mineral composition of colostrum 
and breast milk is materially different. Table 19 shows the com- 
position of one hundred grams of colostrum as compared with one 
hundred grams of milk. 6 

The findings of Burr, Bermerich and Berg 7 were somewhat 
different. They found that colostrum contained twice the amount 
of phosphorus, magnesium and calcium normally present in milk 
after lactation is well established. 

Colostrum Corpuscles. — Microscopically the fat droplets in 
colostrum are more unequal in size than in ordinary milk. The 

1 Burr, Bermerich and Berg: Chem. Ztg., xxxvii, 69-71, 97-101. 

2 Konig, J. : Die Menschl. N'ahrungs u. Genussmittel, Berlin, 1904, ii, 598. 

3 Pf eiffer: Jahrb. f. Kinderh., 1883, xx, 365. 

4 Adriance, V. and J.: Archives of Pediatrics, 1897, xiv, 22. 

5 Camerer and Soldner: Ztschr. f. Biol., 1898, xxxvi, 277. 

6 Birk: Monatschr. f. Kinderh., 1910-1911, ix, 595. 

7 Berg: Chem. Ztg., xxxvii, 146. 



AND INFANT FEEDING 

TABLE 19 
Composition op 100 Gm. Colostrum as Compared with Milk (Birk) 



Colostrum (Birk) 


Human milk 


Ash 

Calcium 


..0.2814 

..0.0360 

..0.0093 

..0.077 

..0.0544 
..0.1137 


0.0198 

0.2 -0.25 

0.0328-0.0343 . . 
0.0378 


. . .Langstein and Meyer 

. . .Abu-Neuberg 

. . .Bunge 

. . .Camerer and Soldner 


Magnesium 


0.0064-0.0065 .. 
0.0053 


. . .Bunge 

. . .Camerer and Soldner 


Potassium 

Sodium 


0.078 -0.0703 .. 

0.088 

0.0357 


. . . Camerer and Soldner 
. . . Camerer and Soldner 
. . .Camerer and Soldner 


Phosphorus 


0.0473-0.0469 .. 
0.0591 


. . . Bunge 

. . .Camerer and Soldner 







colostrum also contains large numbers of granular bodies, known as 
" colostrum corpuscles." They are four or five times as large as the 
leukocytes, are nucleated and are full of fat droplets. They are 
characteristic components of milk at the beginning of lactation, and 
are not found in later lactation. They have ameboid motion. 1 
Czerny identified them as large leukocytes, whose cell membranes 
are completely filled with fat drops. These fat drops are smaller 
than those in the milk. He was able to demonstrate that the leu- 
kocytes of frogs possess the power of emulsifying fat drops and 
explains their small size in this way. He further emphasized the 
fact that it had previously been thought that these bodies were 
only present in the milk during the first days of lactation. Buch- 
holz 2 noticed in 1877, however, that the colostrum bodies reap- 
peared in the milk when nursing was stopped and the milk was 
drying up. Czerny repeated his work and found that the colostrum 
bodies always reappeared in the milk when lactation was inter- 
rupted for a few days, and that their numbers increased in direct 
proportion to the length of time which had elapsed since the breasts 
were emptied. He concluded that colostrum corpuscles were 
always present when milk was formed in the breasts but was not 
withdrawn and that they disappeared when the breasts were 
sufficiently emptied of milk. Animal experiments show that the 
colostrum bodies pass from the breasts into the lymphatics. These 
colostrum corpuscles contain neutrophilic granules. 3 According to 

1 Czerny and Keller, page 409. 

2 Czerny and Keller, page 410. 

3 Cohn: Virchow's Arch. f. path. Anat., 1900, clxii, 187. 



96 DISEASES OF NUTRITION 

Deville, 1 they disappear from the milk between the eighth and 
tenth day in 51% of the cases. They may, however, in rare in- 
stances persist for many weeks. 2 

They are also phagocytic, in that they will consume bacteria. 
They have been shown to consume staphylococci, the colon bacil- 
lus, and the tubercle bacillus. 3 

When the breasts are not completely emptied, the protein and 
sugar are reabsorbed into the body earlier than the fat, which is 
taken up by the colostrum corpuscles only after five or six days. 
The sugar may appear early in the urine. The albumins in milk 
have a different hemolytic action from those in the blood of the 
same species, while those in colostrum react the same. On the 
basis of these facts, Bauer 4 argues* that the proteins in colostrum 
are a direct transudate from the blood, while those in milk are 
manufactured by the mammary gland. 

The protein of colostrum is characteristic since the greatest part 
of it will coagulate. Acid coagulation occurs very easily and the 
curd is tough. 

The colostral fat is richer in oleic acid than is milk fat and as a 
result the iodin index is considerably higher. 5 

HUMAN MILK 

Bacteriology. — Since the infant takes the milk directly into 
the mouth from the breasts, only such organisms as are in the 
breast gland itself can get into the milk. 6 

These investigations show that the milk of healthy women, 
whose breasts are free from pathologic conditions, contains micro- 
organisms in the majority of instances. In the majority of cases 
the organism is staphylococcus aureus. Most investigators believe 

1 Deville: Arch, internat. de med. leg., 1913, iv, 60. 

2 Steele: Arch. Pediat., 1910, xxvii, 32. 

3 Thomas: Vortr. geh. a. d. Vereinig, Sachs-Thuring; Kinderarzte in Dres- 
den, 1913, Ref.; Ztschr. f. Kinderh. (Ref.), 1913, vi, 28. 

4 Bauer: Deutsch, med. Wochenschr., 1909, xxxv, 1657. 

5 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

6 Escherich: Fortschr. d. Med., 1885, iii, 231; Cohn and Newmann: Vir- 
chow's Arch. f. path. Anat., 1891, cxxvi, 391; Palleske: Virchow's Arch., 1892, 
cxxx, 185; Honigmann: Ztschr. f. Hyg. u. Infectionskr., 1893, xiv, 207; Ringel: 
Munchen. med. Wchnschr., 1893, xl, 513; Genoud: Sur la presence du staphy- 
locoque dans la lait des accouch6es bien portantes, These de Lyon, 1894; 
Knochenstiern: Hyg. Rundschau, 1894, iv, 231; Halleur: Inaug. Diss. Leipzig, 
1893; Brumm: Arch. f. Gynaecol., 1886, xxvii, 461; Merit: These de Paris, 1887; 
Johanessen: Jahrb. f. Kinderh., 1895, xxxix, 398; Roeper: Inaug. Diss., Mar- 
burg, 1896; Koestlin: Arch. f. Gynaecol., 1897, liii, 201. 



AND INFANT FEEDING 97 

that the bacteria get in from the outside. Evidence in favor of 
this view is the fact that it is easier to demonstrate these organisms 
in the first part of the milk drawn than in the last part. Finally 
when the milk is withdrawn gently drop by drop, rather than 
strongly and rapidly, many tests are sterile. This fact makes it 
seem probable that the rough handling of the breast gland during 
nursing or by massage dislodges the bacteria and forces them into 
the milk. 

Syphilitic lesions have been induced in rabbits by inoculating 
them with milk from syphilitic women, although the milk was 
sterile and no spirochaeta pallida were found in the milk. 1 

Typhoid bacilli have been found by Lawrence 2 in the milk of 
a woman suffering with typhoid fever. 

Under normal conditions no ill effects are caused by the bac- 
teria in human milk. The children who take this milk thrive in 
spite of the presence of bacteria in the first portion of the milk. 
The bacteria in human milk have no pathologic significance for 
the healthy infant. It has been shown that this is not the fact in 
babies with disturbances of digestion. Moro 3 has recently as- 
cribed to the staphylococci in human milk an etiologic role in the 
dyspeptic conditions of breast-fed infants. 

Appearance, Smell and Taste. — Human milk has the same 
appearance as cow's milk, except that, when it is cooled, small 
white flakes are apt to stick to the side of the bottle. These flakes 
disappear when the milk is warmed. It has no odor and its taste 
is sweet. When the color becomes yellower than that of cow's 
milk it is due to an increased percentage of fat. 

Microscopic Appearance. — It contains many minute fat drop- 
lets which are held in a state of permanent emulsion by the 
solution in which they are suspended. It may contain a few 
leukocytes and epithelial cells. The ultramicroscope shows nu- 
merous fine particles in lively molecular motion between the fat 
droplets. These particles are less numerous than in cow's milk. 
They are composed of casein. 4 

Specific Gravity. — The specific gravity averages between 1.030 
and 1.032. It may fall as low as 1.020 and rise as high as 1.036. 5 

1 Uhlenhuth and Mulzer: Deutsch. med. Wochenschr., 1913, xxxix, No. 19. 

2 Lawrence: Boston Med. and Surg. Jour., 1909, clxi, 152. 

3 Moro: Jahrb. f. Kinderh., Hi, 542. 

4 Alexander and Bullowa: Jour. Am. Med. Assn., 1910, lv, 1196; Mauntner: 
Arch. f. Kinderh., 1908-9, xlix, 29; Kreidland Neumann: Pfliiger's Arch., 1908, 
cxxiii, 523. 

5 Engel: In Somm erf eld's Handbuch der Milchkunde, Weisbaden, 1909, 
p. 774; Konig: Note 9. 



98 



DISEASES OF NUTRITION 



Reaction. — The reaction of human milk is amphoteric. It is 
acid to phenolphthalein and alkaline to litmus. The reason for 
the double reaction is the fact that the milk contains both mono- 
and diphosphates. The former are weakly acid, while the latter 
react as a base. If 10 c. c. of human milk are titrated with deci- 
normal acid and litmus, it will require about 0.9 to 1.25 N/10 acid 
to neutralize them; it requires 0.12 to 0.55 N/10 NaOH with 
phenolphthalein. One hundred cubic centimeters of milk require 
60 to 80 c. c. N/10 HC1 to show the Gunzburg reaction. 1 The 
alkaline reaction of human milk is relatively stronger than the 
acid reaction, but the absolute amount of acidity and alkalinity 
are less than in cow's milk. The electrical measurement of human 
milk as well as of all other milks is neutral. 2 

Quantity. — The amount of human milk secreted by healthy 
mothers depends on the demands of the infant. The twenty-four- 
hour amount of milk, therefore, depends in large part on the 
weight and strength of the infant. It is obvious that what might 
be a normal amount for one infant would be abnormal for another, 
and for this reason averages are of no greater value than the aver- 
age weight of the infant. The figures representing the amount of 
milk taken by the infant are obtained by weighing either the 
mother or the baby before and after each nursing. The table of 
Cramer's 3 figures shows the difference between the secretion of 
milk in primiparse and multiparas : 

TABLE 20 

Twenty-Four Hour Amount of Milk in Grams 



Day -postpartum 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


Nine babies of primiparae; 
average birth weight, 
3,290 gm 

Seven babies of multi- 
parse; average birth 
weight, 3,348 gm 


4 
6 


78 
129 


183 

238 


199 
324 


236 
344 


299 
324 


303 
361 


274 

365 


362 
384 


384 
415 



Table 21 from Czerny and Keller 4 gives the figures that Feer 
calculated as the amount of milk babies of the average weight 

1 Courant: Pfliiger's Arch., 1891, i, 109; Escherich: Verhandl. d. Versamml. 
d. Ges. f. Kinderh., Heidelberg, 1889, 109. 

2 Foa: Soc. Biol., 1905, lviii, 863; 1905, lix, 51. 

3 Cramer: Klin. Beitr. z. Frage der kunstlichen Ern'ahrung des Neuge- 
borenen. Inaug. Diss., Breslau, 1896. Taken from Czerny and Keller, Des 
Kindes, etc., Vol. 1, p. 356. 

4 Czerny and Keller: i, 353. 



AND INFANT FEEDING 



99 



(Camerer's figures) would take in a day. They do not differ 
much from those given by Camerer. 

Czerny and Keller * (Vol I, Chapter 18) should be consulted 
for a more detailed discussion of the amounts of breast milk se- 
creted by the average woman. These amounts may be increased 
when a woman nurses two or more babies as does the wet-nurse. 
A wet-nurse 2 increased the amount of milk secreted in ten days 
from 720 grams when she nursed two infants to 1,750 grams when 
she nursed five infants. 

TABLE 21 

Average Daily Amount of Milk Drawn by a Baby (From Czerny and 

Keller) 





Average 






Average 






weight of 


The calcu- 




weight of 


The calcu- 


Age in 
weeks 


breast-fed 
babies ac- 


lated day's 
amount of 


Age in 
weeks 


breast-fed 
babies ac- 


lated day's 
amount of 




cording to 
Camerer, 


milk, gm. 




cording to 
Camerer, 


milk, gm. 




gm. 






gm. 




1 


3,410 


291 


14 


5,745 


870 


2 


3,550 


549 


15 


5,950 


878 


3 


3,690 


590 


16 


6,150 


893 


4 


3,980 


652 


17 


6,350 


902 


5 


4,115 


687 


18 


6,405 


911 


6 


4,260 


736 


19 


6,570 


928 


7 


4,495 


785 


20 


6,740 


947 


8 


4,685 


804 


21 


6,885 


956 


9 


4,915 


815 


22 


7,000 


958 


10 


5,055 


800 


23 


7,150 


970 


11 


5,285 


808 


24 


7,285 


980 


12 


5,455 


828 


25 


7,405 


990 


13 


5,615 


852 


26 


7,500 


1,000 



Coagulation. — The recent observations with the ultramicro- 
scope 2 have helped to explain the coagulation of milk. The essen- 
tial differences in the coagulation of human and cow's milk are 
as follows : The casein of human milk is precipitated with greater 
difficulty with acids or salts and it does not coagulate uniformly 
after the addition of rennet; and, lastly, the clot that forms does 
not appear in such large coarse masses as the casein from cow's 
milk, but is more loose and fiocculent. 

1 Czerny and Keller: i, 353. 

2 Czerny and Keller: i, 458. 



100 DISEASES OF NUTRITION 

(a) Precipitation with Acids. — Bienenfeld 1 showed that there 
is a certain acidity at which the casein is precipitated most easily. 
When lactic acid is used, this point is between 22 and 24 c. c. N/10 
acid to 100 c. c. of milk. If the milk is made acid up to this point 
and warmed to 40 C. (104 F.) the casein precipitates out of the 
solution. If the milk is diluted five times, the precipitation is 
accelerated. A watery, clear whey is left behind. Engel 2 showed 
that this was also true of strong acids (20 to 30 c. c. N/10 acid to 
100 c. c. milk), but the best results were only seen at a certain de- 
gree of acidity. Slight variations above or below this point did 
not give good results. When acetic acid is used, more is neces- 
sary, i. e., 60 to 160 c. c. N/10 of the acid to 100 c. c. milk. 

(b) Rennin Coagulation. — If a neutral solution of rennet is 
added to milk there is no macroscopic or microscopic change until 
the milk is acidified, but the ultramicroscope shows that the rennin 
ferment acts also in neutral solutions. 3 Although human milk 
does not coagulate uniformly with rennin, it has been shown that 
it is capable of coagulation. 4 After human milk has been frozen 
several days and then rennin plus acid are added, there is a def- 
inite coagulation. Human milk does not coagulate with rennin 
alone. Two factors may explain the diminished coagulability of 
human milk, viz., the relative alkalinity of the milk and its low 
calcium content. 5 Engel 6 saw a better precipitation when he 
diluted the milk with water that contained calcium, than when he 
used distilled water. The coagulation is also facilitated, if the 
milk is kept cold for several hours. 7 

The precipitate is characteristic and is always in more or less 
fine curds, which are never as large as the curd from acidified cow's 
milk. The curds in undiluted milk are especially fine and can be 
seen only with the microscope. It is interesting that they do not 
sink to the bottom in milk from which the cream has not been 
removed, but rise to the top. In skimmed milk they may fall to 
the bottom. 

(c) The Difference between Acid and Rennin Coagulation. — 
There is no macroscopic difference. The ultramicroscope shows 
that neutral solutions of rennin cause the casein, which was pre- 
viously invisible, to become visible. 3 Acid must subsequently 

1 Bienenfeld: Biochem. Ztschr., 1907, vii, 262. 

2 Engel: hoc. cit. } Note 19, p. 775. 

3 Kreidl and Neumann: (See note 4, 97). 

4 Schlossmann and St. Engel: Oppenheimer's Handbuch, etc., iii, 430. 

5 Fuld and Wohlgemuth: Biochem. Ztschr., 1907, v. 119. 

6 Engel: Biochem. Ztschr., 1908, xiii, 89. 

7 L. F. Meyers: Verhandl. d. ges. f. Kinderh., Stuttgart, 1906, p. 122. 



AND INFANT FEEDING 



101 



be added to cause a definite precipitation. The curds from acid 
plus rennin coagulation are not so easily dissolved as those from 
acid coagulation alone. Chemically there results from rennin 
coagulation a casein body, which is rich in calcium — paracasein. 
The whey which results from rennin and acid coagulation, con- 
tains less nitrogen than that from acid precipitation. 1 

Chemical Composition. — The principal components of milk are 
fat, lactose, proteins, salts and water. It also contains small 
amounts of extractives and citric acid as well as certain unknown 
substances. 

Nitrogenous Bodies. — 1. Total Nitrogen. The total nitrogen 
in milk is usually determined by the Kjeldahl method and this 
figure is multiplied by the factor 6.25, or 6.37, to give the albumin 
content. This method is, however, not free from error, because 
there are other bodies that contain nitrogen and yet are not classed 
among the albumins. These, according to various authors, 2 may 
make up between 17 and 20% of the total nitrogen. Taking this 
fact into consideration and deducting the non-albuminous nitro- 
gen from the total nitrogen, there is, according to Camerer and 
Soldner, 1.04% of albumin in human milk. The average figures 
as to the total amount of nitrogen in 100 c. c. of milk at different 
stages of lactation are 3 as shown in the following table : 



Total Nitrogen in 100 C. 



TABLE 22 

C. Milk at Different Stages in Lactation 

(Schlossmann) 



Days post partum 


Total nitrogen 


Nitrogen factor X6.25 


9 to 10 


0.29 


1.81 


11 to 20 


0.29 


1.81 


21 to 30 


0.31 


1.94 


31 to 40 


0.24 


1.50 


41 to 50 


0.28 


1.75 


51 to 60 


0.25 


1.56 


61 to 70 


0.23 


1.44 


71 to 100 


0.20 


1.25 


101 to 140 


0.20 


1.25 


141 to 200 • 


0.207 


1.29 


Over 200 


0.21 


1.31 



x Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

2 Camerer and Soldner: Ztschr. f. Biol., N. F., 1898, xviii, 277; Rietschl: 
Jahrb. f. Kinderh., lxiv, 125. 

8 Schlossmann: Arch. f. Kinderh., 1900, xxx, 324; 1902, xxxiii, 187. 



102 



DISEASES OF NUTRITION 



The amount of albumin in the milk varies during the same day 
and even during a single nursing. These variations are, however, 
not of any great significance. The next table shows the variations 
in the milk of eight wet-nurses during a single day, samples having 
been taken from each of the nursings. The individual variations 
are so slight, however, that if the average for the day is taken 
and compared with the average for the stage of lactation, the same 
diminution in the amount of albuminous material during the prog- 
ress of lactation is seen as in the table. 1 (The factor of nitrogen 
times 6.25 was used.) 

TABLE 23 



Variation 


[N THE 


Milk 


op Eight Wet-Nurses 


During 


a Single Day 


(Engel) 






Age 


Day 


















of 


of 






Morn- 






After- 




Avg. 


nurse, 


lacta- 


Ain't, 




ing 






noon 




years 


tion 


c. c. 


5 


9 


12 


3 


6 


10 




16 


45 


2,000 


1.386 


1.458 


1.305 


1.324 


1.306 


1.279 


1.344 


19 


58 


1,500 


1.163 


1.118 


0.956 


1.073 


1.163 


1.127 


1.100 


29 


60 


2,200 


1.149 


1.154 


1.395 


1.261 


1.136 


1.161 


1.208 


25 


70 


2,700 


1.314 


1.243 


1.127 


1.216 


1.046 


1.064 


1.170 


23 


72 


3,000 


1.207 


1.234 


1.154 


1.315 


1.154 


1.163 


1.204 


21 


100 


3,300 


1.135 


1.117 


1.127 


1.154 


1.243 


1.028 


1.119 


19 


130 


1,800 


0.492 


1.019 


1.127 


1.064 


0.903 


1.082 


0.948 


25 


140 


2,200 


1.082 


1.064 


1.100 


0.939 


1.082 


1.064 


1.036 




Avg. 


1.141 



2. Residual Nitrogen. — The residual nitrogen is that fraction 
of the nitrogen which is found in the filtrate after the precipita- 
tion of the albumins and which does not give the reactions for 
protein. 2 Part of this residual nitrogen is supposed to be in the 
form of urea (50% or more) and another part in an amino-acid or 
a peptid-like body. 3 There is less of it in cow's milk than in hu- 
man milk. The significance of these bodies is unknown. 

The milk and blood serum of a 21-year-old primipara with 
chronic nephritis (urinary albumin=0.3%) were simultaneously 
examined on two occasions. The residual nitrogen of the serum 
was 5.33% and 7.43% of the total nitrogen; that of the milk was 

1 Engel: In Sommerfeld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

2 Munk: Virchow's Arch. f. path. Anat., 1893, 134, 501. (First studied 
this body.) 

3 Rietschel: Jahrb. f. Kinderh., lxiv, 125. 



AND INFANT FEEDING 103 

27.19% and 32.88%, both being much above the normal. Urea 
was considered to be the probable cause of this increased amount. 1 

3. The Albuminous Bodies. — Human milk contains two groups 
of albuminous bodies: (1) casein, which is insoluble in water, and 
(2) lactalbumin and globulin, which are soluble in water. The 
separation of these bodies in human milk is more difficult than in 
cow's milk, because of the difficulty in precipitating the casein. 
There is, on this account, much opportunity for future investiga- 
tions to add to our knowledge of the proteins of human milk. The 
figures which are most generally adopted are those of Schloss- 
mann, 2 who found that about 41% of the total nitrogen is in the 
form of casein. From 15 to 20 % of the total nitrogen may, how- 
ever, be residual nitrogen (see above). If this amount is deducted 
only 44 to 39% are left to be divided between the lactalbumin and 
globulin. Ciccarelli 3 found that the relation of casein to lactal- 
bumin in human milk was 26.9-37.9 to 62.1-73.1. These figures 
show that there is considerable variation in the quantities of these 
bodies even in human milk. The following figures represent what 
may be considered averages. The total protein is divided as fol- 
lows: 

Casein, 41%; lactalbumin and globulin, 44 to 39%; residual 
nitrogen, 15 to 20%. 

Opalisin was described in 1888 by Wroblewski 4 as a new al- 
bumin which is present in very small amounts in cow's milk and 
in large amount in mare's milk. It is also present in human milk. 
Very little is known about this body. 

COMPARISON OF PROTEINS OF HUMAN AND COW'S MILK 

Casein. — The facts that it is difficult to precipitate casein from 
human milk and that it takes large amounts of milk to obtain a 
sufficient quantity of casein for analysis have retarded our knowl- 
edge of the subject. For this reason more is known about cow 
casein than human casein. 

Casein is insoluble in water, but is soluble in water to which 
alkalies have been added. If acid is added to this alkaline solu- 
tion, the casein will again be precipitated. If enough alkali is 
subsequently added it will again go into solution. The analysis 
of casein is shown in table 24. 

1 St. Engel and Murschauser: Ztschr. f. physiol. Chem., 1911, Ixxiii, 101. 
2 Rietschel: Jahrb. f. Kinderh., Ixiv, 125. 

3 Ciccarelli : La Pediatria, 1908, vi, 12. 

4 Wroblewski: Ztschr. f. Physiol. Chem., 1898-99, xxvi, 308. 



104 



DISEASES OF NUTRITION 



TABLE 24 

Analysis op Casein (From Engel) 



Author 


C 


H 


S 


P 


N 


Wroblewski 1 


52.24 
53.01 
52.63 


7.32 
7.14 
6.94 


1.12 
0.71 
0.85 


0.68 
0.25 
0.27 


14.97 


Bergell and Langstein 2 . . 


14.60 
14.34 



The sulphur content of cow and human casein is as follows: 



Cow Casein 
Liebig 3 Hempel 3 

0.723 0.723 



Human Casein 
Liebig Hempel 



0.094-1.079 



1.072 



According to these figures there is more sulphur in human than 
in cow's milk. They correspond closer to Wroblewski's figures 
than to those of Bergell and Langstein. It is still a disputed ques- 
tion whether the casein from different kinds of milk is identical 
or whether there are several different caseins. Recently Lang- 
stein and Edelstein found that the phosphorus content of human 
milk was 0.22 to 0.28% and that of cow's milk 0.85 to 0.87% and 
concluded that this was evidence that the two caseins were dif- 
ferent compounds.. 

Bordet 4 showed that repeated injections of cow's milk into 
other animals caused a body to appear in the blood which precipi- 
tated the albuminous bodies of cow's milk and made them co- 
agulate. Wasserman 5 and others went a step further and showed 
that the blood serum of animals sensitized to cow's milk would 
precipitate the albuminous bodies in cow's milk, but would not 
precipitate those in human milk or the milk of other animals, 
and that the blood serum of animals sensitized to human milk 
precipitates the albuminous bodies in human milk and does not 
precipitate them in the milk of other animals. In other words, 
the blood serum of an animal may be sensitized to the albumins 
of a certain species of animal and react specifically to that species. 
These experiments can leave no doubt that the proteins of different 
animals are different. 

Further investigations showed that casein, lactalbumin and 

1 Wroblewski: Ztschr. f. Physiol. Chem. 1898-99, xxvi, 308. 

2 Bergell and Langstein: Jahrb. f . Kinderh., 1908, lxviii, 568. 

3 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

4 Bordet: Ann. de l'lnst. Pasteur, 1899, xiii, 240. 

5 Wasserman: Verhandl. des 18 Congr. f. inn. Med., 1900, p. 501. 



AND INFANT FEEDING 105 

globulin could be differentiated from one another by complement 
fixation and anaphylaxis experiments. 1 Milks of animals of one 
species can, therefore, be differentiated from the milk of animals 
of another species and the casein, globulin and lactalbumin of the 
same milk can be differentiated one from the other. 

Fat. — The fat in human milk is in a very fine emulsion. When 
the number of drops are counted in a counting chamber there- are 
always more in human milk than in cow's milk. 2 The fat globules 
in human milk measure between 0.001 and 0.02 mm., while those 
in cow's milk measure 0.0016 to 0.01 mm. 3 Since the measure- 
ments given above show that the fat drops in human milk may be 
of greater diameter than those in cow's milk, it seems inconsistent 
that there should be a larger number in the former than in the 
latter. The explanation must be that the majority of fat drops 
in human milk are small and measure about 0.001 mm., while the 
majority of those in cow's milk must be closer to the upper limit 
and measure nearly 0.01 mm. 

Percentage and Quantity of Fat. — The figures as to the per- 
centage of fat and the total amount of fat in human milk vary 
considerably according to the various investigators and the methods 
they pursue in obtaining their material. Engel's 4 monograph 
on human milk gives the most complete summary of the knowl- 
edge of this subject and is quoted freely in the following paragraphs. 
The percentage of fat is smallest at the beginning of nursing and 
largest at the end of nursing, the steepness of the curve depending 
on the total amount of milk taken at a nursing. When a small 
amount is taken, there is a sharp rise in the percentage of fat, 
and when there is a large amount of milk taken, there is a more 
gradual rise. Although the percentage may increase regularly 
throughout the nursing, this is by no means the rule. The three 
curves taken from Engel give examples of how the percentages of 
fat may increase (see Chart). 

The percentage of fat in the first milk drawn varies between 1 
and 3 % and that in the last milk taken between 6 and 10%. These 
figures may occasionally be even higher. There are cases on record 
in which there was more fat in the first part of the milk than in 

1 Bauer and St. Engel: Biochem. Ztschr., 1911, xxxi, 46; Kleinschmidt : 
Monatschr. f. Kinderh., 1911-1912, x, 402. 

2 Czerny and Keller: Des Kindes; Ernahrung, ErnahrangsstSrungen, und 
Ernahrungstherapie, Leipzig and Wein, 1906, 1, 407. 

3 Leaves: Ztschr. f. physiol. Chem., 1894, xix, 369; Ruppel: Ztschr. f. Biol., 
1894, xxi, 1. 

4 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 



106 



DISEASES OF NUTRITION 



the last part and the curve is the reverse of the one just described.* 
In pathological conditions the extremes of the percentage of 
fat are 0.1% 2 and 13.7%. 3 

The average fat content of the milk of ten wet-nurses (German) 
examined by Engel was 4.5%, and of 119 women (Russian) ex- 
amined by Skvortzov, 4 3%. The amount of fat in the milk of 
the same women may vary from 25 to 100% in the same day at 
different nursings. When the intervals of emptying the breasts 
are long there is more milk and less fat. When all the milk of a 
woman is collected each day the average daily percentage is con- 
stant. This is true even if the total amount of milk is considerably 
increased. 

Quality of Fat.— When fat is separated from human milk by 
dissolving it in ether, it forms a yellowish-white mass similar, at 
room temperature, to butter. 



CHART IV 

Chart from Engel.— The heavy black line indicates the increase in the per 
cent of fat when the milk is examined at frequent intervals during a single 



nursing. 



FAT 
7 
6 
5 
4 
3 
2 
1 


WET - NURSE G 
29, VIII. '05,6 P.M. 


FAT 

i 

7 
6 
5 
4 
3 
2 


WET- NURSE K 
22, VI. '05,6 P.M. 


FAT 
8 

7 

6 

5 
4 

3 

2 
1 


WET - NURSE M 
13. V, '05 




















1 






















































































































































s 
/ 




























• 














s 
/ 




























s 










| ( 


- — / 


• 


























• 


* 












/. 


• 


























• 


< 


/ 










_J 


y 


























y 


*— 














F 
















/ 


' 


























































































































































































1 



































G.e. 



100 150 



100 150 200 



1 Engel: Arch. f. Kinderh., 1906, xliii, 181. 

2 Moll: Arch. f. Kinderh., 1908, xlviii, 161. 



3 Engel: Arch. f. Kinderh., 1906, xliii, 194. 

4 Skvortzov: Russki Vratch ii, p. 1392; Ref. Chem. Abstracts, 1913, vn, 
No. 18. 



AND INFANT FEEDING 107 

The melting point of human milk is between 30 and 34 C. 

The solidifying point is between 19 and 22.5 C. 

The specific gravity at 15 C. is 0.97. 1 

The fat of human milk is relatively poor in volatile fatty acids 
when compared with cow's milk. 

Volatile fatty acid, human milk, 2.5% of total fat. 

Volatile fatty acid in cow's milk, 27.0% of total fat. 

Among the volatile fatty acids have been demonstrated butyric, 
capronic, caprinic and caprylic acids. One-half of the non-volatile 
fatty acids are oleic acid, while among the solid fatty acids myristic 
and palmitic acids are found to be more abundant than stearic 
acid. 2 The large amount of oleic acid explains the relatively lower 
melting point and higher iodin value of human milk than of cow's 
milk. 

The iodin value of the fat in human milk varies within fairly wide 
limits, but is usually found at about 45. There are women in 
whom it sinks to 32 and others in whom it is as high as 50. 3 Cer- 
tain observations go to show that the iodin value is in part depen- 
dent on the food. Goose fat, linseed oil 4 and iodized fats 5 have 
been demonstrated to pass from the food into the milk. 

Lactose. — Lactose, or milk sugar, is found only in the milk 
of animals. It is essentially the same in the milk of the woman, the 
cow, ass, rabbit, dog and horse. 6 There is evidence 7 which sug- 
gests strongly that lactose is formed from the dextrose in the 
blood. The quantity of lactose varies the least of all the elements 
of human milk. The amount of lactose in human milk is almost 
twice that in cow's milk, being on the average about 7%. The 
lowest percentage which has been found is 4.22 8 and the highest 
10.9%. 9 A few instances have been recorded in which the addition 
of sugar to the diet of the mother has increased the amount of sugar 
in the milk. This is, however, by no means the rule. 10 

1 Ruppel: Ztschr. f. Biol., 1894, xxxi, 1; Laves: Ztschr. f. physiol. chem., 
1894, xix, 369; Sauvaitre: Ref., Malys. Jahresb. d. Tierchemie, 1903, xxxiii, 324. 

2 Hammersten: English translation Text-book Physiological Chemistry, 
N. Y., 1909, p. 530. 

3 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909. 

4 Thiemich: Monatschr. f. Geburtsh. u. Gynak., 1899, ix, 515. 
6 Bendix: Deutsch. med. Wochenschr., 1898, xxiv, 223. 

6 Deniges: Contribution a l'etude des lactoses, Paris, 1892; Bonmartini: 
Rev. gem du lait, 1906, ii, No. 1. 

7 Porcher: Biochem. Ztschr., 1909-10, xxiii, 370; Paton and Cathcart: 
Jour, of Physiol., 1911, xlii, 179. 

8 Pfeiffer: Verh. II, Versaml. d. Gesselsch. f. Kinderh., Wien, 1894, p. 131. 

9 Schlossmann: Arch. f. Kinderh., 1900, xxx, 324. 
10 Lust: Monatschr. f. Kinderh., 1913, xi, 236. 



108 



DISEASES OF NUTRITION 



Lecithin. — It has been estimated that 100 c. c. of human milk 
contains 0.058 gm. of lecithin. 1 The question has been raised, 
however, whether the body that was quantitated as lecithin was 
not a result of the breaking down of some of the phosphorus- 
containing bodies by the chemical manipulations during the 
investigation. 

Nuclein. — There is considerable debate as to whether human 
milk contains nuclein or not. Three cases which were examined 2 
showed an average per cent during one year as follows: 0.1302, 
0.1339 and 0.1305. The amount was inversely proportional to the 
quantity of the milk. 

Salts. — Total Ash: The average amount of ash in human 
milk is about 0.2 1%. 3 The amount of ash diminishes during the 
course of lactation just as. does that of the protein. This is shown 
in the following from Camerer and Soldner: 

Days postpartum Per cent of ash 

8- 11 days 0.28 

29- 40 days 0.22 

60-140 days 0.19 

170 days and later . . 0. 18 

The following table shows the percentage of the various salts in 
human milk to 100 parts of ash. 

TABLE 25 

Percentage op Salts in Human Milk to 100 Parts of Ash (From Engel 

and schloss) 



Bunge 



Blackhans and 
Kronheim 5 



de Lange 6 



Schloss 7 



I 

K 2 32.14 

Na 2 11.75 

CaO 15.67 

MgO.. 3.99 

Fe 2 3 0.27 

P 2 5 21.42 

CL 20.35 



I 

33.74 
11.91 
17.36 
3.17 
0.63 
14.79 
15.47 



II 

27.33 
15.88 
15.52 
2.13 
1.75 
11.75 
23.93 



19.9 
29.6 
12.9 
2.9 
0.25 
17.9 
21.3 



28.77 

10.26 

20.44 

4.66 

22.0 
16.61 






1 Burow: Ztschr. f. Physiol. Chem., 1900, xxx, 506. 

2 Valenti: Chem. Zentralbl., 1909, i, 93. 

3 Camerer and Soldner: See Note 5, p. 94; Pfeiffer: Verh. d. gesellsch. f. Kin- 
derh., Wien, 1894, p. 126. 

4 Bunge: Ztschr. f. Biol., 1874, x, 316. 

5 Bericht d. landw. Inst. d. Univ. Konigsberg, v. 61. 

6 De Lange, Cornelia: Ztschr. f . Biol., 1900, xl, 527. 

7 Schloss: Ueber Sauglingsernahrung, Berlin, 1912, p. 58. 



AND INFANT FEEDING 



109 



The composition of the ash of human milk is, according to 
Soldner * as shown in table 26. 

TABLE 26 

Composition of Ash of Human Milk (From Engel) 





100 gm. milk contains, 
milligrams 


100 gm. ash contains, 
milligrams 




First milk 


End milk 


Average 


First milk 


End milk 


Average 


K 2 

Na 2 

CaO 

MgO 

Fe 2 3 

P2O5 

S0 3 

CI 


100.8 

44.8 

37.6 

5.4 

0.22 

32.10 

9.6 

71.7 


63.4 

17.6 

38.1 

5.2 

0.12 

28.8 

7.2 

34.2 


88.4 

35.7 

37.8 

5.3 

0.2 

31.0 

9.0. 

59.1 


32.5 

14.5 

12.1 

1.7 

0.07 

10.40 

3.1 

23.1 


31.9 
8.9 

19.2 
2.6 
0.06 

14.50 
3.6 

17.3 


32.4 

13.1 

13.9 

1.9 

0.07 

11.40 

3.3 

21.7 







These figures show that the ash varies in amount, as well as other 
milk components, according to whether the sample of milk is taken 
at the beginning or at the end of nursing. It is obviously just as 
necessary to obtain milk under the same conditions and with the 
same precautions when the salts are to be investigated as when the 
other food components are to be studied. 

Calcium. — A large number of analyses show wide individual 
variations between 0.03 and 0.08%, with an average of 0.042 to 
0.044%. The daily variations may amount to as much as 0.02%. 
The calcium content decreases as the period of lactation progresses. 
The amount of calcium cannot be increased by feeding the mother 
with calcium salts. 2 

Iron. — Friedjung 3 found from 3.52 to 7.21 mg. iron in a liter 
of human milk. This gives an average of 5.09 mg. This figure is 
somewhat higher than those given by Camerer and Soldner 4 
and Bahrdt and Edelstein, 5 who found between 1.215 and 2.93 mg. 
per liter. The iron content of the milk is dependent on the general 
condition of the woman. It is higher in healthy individuals and 

1 Soldner: From Sommerf eld's Handbuch, etc., p. 800. 

2 Bahrdt and Edelstein: Jahrb. f. Kinderh., 1910, lxxii, 16; Schabad: Jahrb. 
f. Kinderh., 1911, lxxiv, 511. 

3 Friedjung: Arch. f. Kinderh., 1901, xxxii, 58; Jolles and Friedjung: Arch. f. 
exper. Path. u. Pharm., 1901, xlvi, 247 (entire literature to date). 

4 Camerer and Soldner: Ztschr. f. Biol., 1900, xxxix, 190; 1903, xliv, 71; 
1905, xlvi, 371. 

5 Bahrdt and Edelstein: Ztschr. f. Kinderh., 1910, 1, 182. 



110 DISEASES OF NUTRITION 

lower in those under par. A regular decrease in the amount of iron 
during lactation has not been demonstrated. Neither have in- 
vestigations of the iron content of the milk in pathologic conditions 
of either the mother or the baby given any figures of clinical 
significance. 

Chlorids. — Freund * found that 1,000 c. c. of the milk of the 
same woman contained, on four successive days: 0.488, 0.498, 
0.433 and 0.456 NaCl. Bunge obtained similar results. 

Phosphorus. — There is a great difference in the form in which 
phosphorus is present in human and in cow's milk. Three-quarters 
of that in human milk is in organic combination, while only one- 
quarter of the phosphorus in cow's milk is in organic combination. 
The phosphorus which is in organic combination is considered by 
many to be in the form of lecithin and nucleon, which are present 
in larger amounts in human than in cow's milk 2 (see lecithin and 
nucleon); 41.5% of the total phosphorus in human milk is in the 
form of nucleon phosphorus and only 6% in cow's milk. 2 Because 
of the larger amount of casein and calcium phosphate which it 
contains, cow's milk is much richer in phosphorus than human milk. 
The relation of P2O5 to N is 1 :54 in human milk, and 1 :27 in cow's 
milk. 3 Keller 4 found that one liter of milk contained of P2O5 



Grams P2O5; 
0.40 
0.44 
0.377 
0.452 
0.353 



. 386 1 1 

n „ Q \ The same woman. 

The mixed milk of different U ' 6 ^ 

wet-nurses. 



Sikes 5 gives 0.297 P2O5 to the liter as an average of figures in the 
first three weeks of life. The amount varies between 0.14 and 
0.522. Schlossmann 3 gives as an average 0.461 P2O5 per liter. 
The phosphorus content of the milk depends in good part on the 
casein content of the milk. 

Citric Acid. — The average amount of . citric acid in human 
milk is 0.05%. 6 

1 Freund: Chlor. und Stickstof in Sauglings organisms, Jahrb. f. Kinderh., 
1898, N. F., xlviii, 137. 

2 Siegfried: Ztschr. f. Phys. Chem., 1897, xxii, 575; Whittmaack: Ztschr. 
f. physiol. Chem., 1897, xxii, 567; Burow: Ztschr. physiol. t Chem., 1900, xxx, 
495. 

3 Schlossmann: Arch. f. Kinderh., 1905, xl, 1. 

4 Keller: Arch. f. Kinderh., 1900, xxix, 1. 

5 Sikes: Jour. Physiol., 1906, xxxiv, 464. 

6 Scheibe : Quoted by Engel. See note 5, p. 96. 



AND INFANT FEEDING 111 

Caloric Value. — The caloric value of one liter of human milk is 
782 calories. 1 

Unknown or Unidentified Substances. — Meigs and Marsh 2 
report the presence of substances of unknown nature which contain 
little or no nitrogen and are soluble in alcohol and ether. Human 
milk immediately after the colostrum stage contains 1% of these 
unknown substances, while milk from the middle period of lacta- 
tion contains about 0.5%; cow's milk from the middle period of 
lactation contains about 0.3% of these substances. 

Viscosity. — There is in most cases a regular decrease in the 
viscosity of milk during the first twenty-four hours postpartum. 
There is no difference between the viscosity in normal or abnormal 
cases then or later. The electrical conductivity is almost always 
increased in abnormal cases. This increase is least when there is 
albuminuria and greatest when the supply of milk is scanty. There 
is a regular decrease in the electrical conductivity during the first 
week postpartum. 3 The degree of viscosity depends on the 
amount of solids in the milk especially of casein. 4 

VARIATIONS IN THE COMPOSITION OF HUMAN MILK 

Table 27, page 112, shows the lowest and highest figures given by 
various authors. These figures show that the variations in the 
percentage of fat are the greatest, but that there are considerable 
differences in the percentages of the other components of human 
milk. There are no figures in literature in which the percentages 
of all components are high or all low. Usually, when one com- 
ponent is increased, another is diminished. 

The average composition of human milk is usually given as 
follows: Fat, 4%; lactose, 7%; protein, 1.50%; (casein 42%, 
filterable nitrogen [including lactalbumin, globulin and unknown 
bodies 58%) ; salts, 0.21%. 

The previous tables show that human milk may vary widely in 
its composition from these figures and still be normal. 

Influence of Food on Quantity and Composition of Milk. — 
The effect of food on the chemical composition of milk has been 
investigated and, with the exception of the work done on fats, does 
not warrant any conclusions. The fat in the milk may diminish 

1 Schlossmann: Archiv. f. Kinderh., 1900, xxx, 288. 

2 Meigs and Marsh: Jour, of Biol. Chem., xvi, No. 1. 
s Polenaar and Phillipo: Ztschr. f. Pathol., ix, 138. 

4 Oertel: Dissertation, Leipzig, 1908, Ref. Arch. f. Kinderh., 1909, li, 

282. 



112 



DISEASES OF NUTRITION 



TABLE 27 

Variations in Composition of Human Milk (from Czerny and Keller) 



Pfeiffer 1 

Johannessen 

and Wang 2 . 
V. and J. S. 

Adriance 3 . . 
Guirand 4 . . . . 
Camerer and 

Soldner 5 . . . 
Schlossmann 6 . 



Fat, 
per- cent. 



0.75-9.05 

2.7 -4.6 

1.31-7.61 
1.75-6.18 

1.28-5.77 

1.65-9.46 



Sugar, 
per cent. 



4.22- 7.65 
5.9 - 7.8 

5.35- 7.95 

6.7 - 7.7 

5.35- 7.52 
5.2 -10.90 



Protein * 
per cent. 



1.049-3.04 

0.9 -1.3 

0.23 -2.60 
0.85 -1.4 

0.82 -1.86 
0.56 -3.4 



Ash, 
per cent. 



0.104-0.446 



0.09 -0.28 
0.10 -0.27 

0.11 -0.36 



Solids, 
per cent. 



8.23-15.559 



9.19-15.31 
11.2 -16.3 

9.41-14.11 



* Nitrogen times 6.25. 

when the mother is underfed. 7 If more fat is given in the diet of 
such an underfed woman, the fat in the milk will increase up to a 
certain point. If, however, large amounts of fat are given to 
women who already have sufficient quantities of fat in the food, 
there is only a temporary increase in the fat in the milk in spite of 
the excessive fat in the diet. 8 Czerny and Keller 9 conclude that 
the milk of nursing mothers cannot be permanently influenced by 
the food, except in those instances in which they do not get suffi- 
cient food, i. e., when they are partially starved. The quantity of 
the milk cannot be increased at will by increasing the amount of 
food or drink. There are a few instances on record in which the 
addition of sugar to the diet of a nursing woman has increased the 
amount of sugar in the milk. Such an increase is, however, by no 
means the rule (see lactose) . 



GALACTAGOGUES 

Schafer and MacKenzie 10 found that the posterior lobe of the 
pituitary body of the ox and the corpus luteum of sheep both act 

1 Pfeiffer: Verhandl. d. II Vers. d. Gesellsch f. Kinderh. in Wien, 1894, p. 131. 

2 Johannessen and Wang: Ztschr. f. Physiol. Chem., 1898, xxiv, 499. 

3 Adriance, V. and J. S. : Arch, of Pediatrics, 1897, xiv, 27. 

4 Guirand: These de Bordeaux, 1897. 

5 Camerer and Soldner: Ztschr. f. Biol., xli, N. F., 18, p. 280. 

6 Schlossmann: Arch. f. Kinderh., 1900, xxx, 324. 

7 Engel and Plaut: Mimchen. med. Wochenschr., 1906, liii, 1158. 

8 Albert: Ref. Malys. Jahresb. f. Thierchemie, 1899, xxix, 253; Henriques 
and Hansen: Jahresb. f . Thierchemie, 1899, xxix, 68. 

9 Czerny and Keller: Des Kindes; Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wien, 1906, 1, 407. 

10 Schafer and MacKenzie: Proc. Roy. Soc, London (B), 1911, lxxiv, 16. 






AND INFANT FEEDING 113 

as galactogogues when injected into cats and dogs. Hammond * 
found that the injection of pituitary extract into lactating goats 
increased the amount of milk for twenty-four hours. The amount 
decreased below the normal during the next twenty-four hours, 
however, so that the average of the two days was the normal 
amount. 2 Gavin did not find the pituitary extract affected the 
quantity of milk in cows. MacKenzie and others 3 believe that 
the mammary gland can be stimulated by the posterior lobe of the 
pituitary body, the pineal body and the corpus luteum. The action 
of the former is supposed to be the most powerful. Inhibitory sub- 
stances are said by some observers to be produced by the fetus, 
placenta, spleen, pancreas, adrenals and thyroid. Aschner and 
Grigori, 4 on the other hand, say that the pulp of placenta or of 
the fetus, or their watery extracts, cause a true secretion of milk 
in virgin animals, and that the body which causes this secretion is 
(contrary to Starling's contention) destroyed by alcohol and heat. 
Basch 5 reports that substances present in the placenta when in- 
jected into animals will bring back the secretion of milk after it has 
stopped. Wolf 6 injected milk into nursing women and found that 
there was an increase in the amount of milk secreted. Chatin and 
Rendu 7 repeated Wolf's work with eight women. They gave 
thirteen injections of milk with the result that in eight instances 
the curve of milk secretion remained stationary or became slightly 
lowered. In the five remaining instances, there was a slight in- 
crease in the amount of milk secreted after the injection of milk. 
This increase was, however, always in association with other fac- 
tors, such as a change in the number of nursings, or a greater de- 
mand on the part of the infant. They believe that the latter were 
the cause of the increase and not the former. 

There is much evidence to show that substances secreted in the 
ovary cause the growth of the breast glands at puberty. Cramer 8 
believes that it has no influence on the hyperplasia of pregnancy, 
while Basch, 9 on the other hand, attributes the increase in size of 
the breast glands to a secretion in the ovary. The blood of a 

1 Hammond: Quart. Jour. Exper. Physiol., 1913, vi, 311. 

2 Gavin: Quart. Jour. Exper. Physiol, 1913, vi, 13. 

3 MacKenzie: Quart. Jour. Exper. Physiol., 1911, iv, 305; Ott and Scott: 
Therap. Gaz., 1911, xxxv, 689. (Experiments on goats.) 

4 Aschner and Grigori: Arch. Gyn., xciv, No. 3. (Guinea-pigs were used.) 

5 Basch: Munchen. med. Wochenschr., 1911, lviii, 2266. 

6 Wolf: Zentralbl. f. Biochem. u. Biophys., 1913, xiv, 224. 

7 Chatin and Rendu: Lyons med., 1912, cxviii, 161. 

8 Cramer: Munchen. med. Wochenschr., 1909, lvi, 1521. 

9 Basch: Munchen. Med. Wochenschr., 1911, lviii, 2266. 



114 DISEASES OF NUTRITION 

pregnant animal injected into a lactating animal has no influence 
on the secretion of milk. 1 Engel concludes that there are no 
artificial means of increasing the secretion of milk. 

FOREIGN BODIES IN HUMAN MILK 

Certain drugs have been proved to be excreted in human milk 
after they have been taken by the mother, but these are present 
only in traces. They are potassium iodid, sodium salicylate, anti- 
pyrin, mercury, 2 aspirin, calomel, arsenic, bromids, 3 urotropin, 4 
and to a certain extent those bodies which are soluble in fat, such 
as the iodinized oils. 2 

Alcohol is found in human and cow's milk in minimal amounts 
after the ingestion of very large amounts, but not after the taking 
of small amounts. 5 It is possible that opium, in the form of mor- 
phin, and atropin may be excreted in human milk, since it has been 
shown that they go over into the milk of animals. 6 They have not 
as yet been found in human milk. 

Salvarsan injected into the syphilitic mother is excreted in the 
milk and after such treatment the syphilitic suckling frequently 
shows remarkable improvement; in some instances the infant has 
suddenly died, so soon after the institution of treatment that death 
seemed to result from treatment. 7 It is evident that such treat- 
ment may not be entirely free from danger. 

INFLUENCE OF VARIOUS PHYSIOLOGICAL AND PATHOLOGICAL 
CONDITIONS ON THE SECRETION OF MILK 

Nervous Impressions. — "Fright, grief, passion, excessive sexual 
indulgence, or any great excitement may entirely arrest the secre- 
tion, or if not arrested the milk may be so altered in composition 
as to make the child actually ill." (Holt.) Although such phe- 

1 D'Errico: La Pediatria, Abstr. in Jahrb. f. Kinderh., 1910, xxii, 504. 

2 Engel: In Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
p. 810. 

3 Bucura: Ztschr. f. Exper. Path. u. Therap., 1907, iv, 398. 

4 Schmid and Schroter: Zentralbl. f. d. ges. Physiol, u. Path. Stoffwechsels, 
1910, v. 129; Rieder: Monatschr. f. Kinderh., 1912, xi, 80. 

5 Voltz: Biochem. Ztschr., 1913, hi, 73. 

6 Czerny and Keller: Des Kindes; Ernahrung, Ernahrungsstorungen, und 
Ernahrungstherapie, Leipzig and Wein, 1906, 1, 407. 

7 Jesionek: Munchen. med. Wchnschr., 1911, lviii, 1169; Jeanselme: Ann. 
de gynec. et d'obst., 1911, 2 Ser., viii, 394; Wolbarst: Am. Medicine, 1911, 
xvii, 486. 



AND INFANT FEEDING 



115 



nomena have been observed clinically, there are no chemical ob- 
servations which tell exactly what the chemical changes are under 
such circumstances, except those give by Rotch. 1 

Menstruation. — Rotch 1 gives the illustration, shown in the 
next table of a case in which the milk was examined during and 
after menstruation. 

TABLE 28 
Effect of Menstruation on Breast-Milk 





Fat 


Lactose 


Protein 


Salts 


Water 


Second day of menstrua- 
tion; child's stools loose. 
Per cent 


1.37 

2.02 

2.74 


6.10 

6.55 
6.35 


2.78 

2.12 
0.98 


0.15 

0.15 
0.14 


89.60 


Seven days after menstru- 
ation; bowels regular. 
Per cent 


89.16 


Forty days later; child gain- 
ing rapidly. Per cent . . 


89.79 



Bendix 2 examined the milk of eight women before, during and 
after menstruation. He concluded that such variations as he 
obtained were not outside of the normal physiological limits. 

Uremia. — Finizio 3 studied the protein content of human 
milk and found that it increased only in nephritis and mild uremia 
(see residual nitrogen). Thiemich 4 concluded, after reviewing the 
literature, that this increase did not affect the nursing infant so 
long as the quantity of the milk and the health of the mother were 
normal. 

Beriberi. — The milk of mothers with beriberi paralyzes the 
heart of frogs quicker than does Ringer's solution. 5 Clinically, 
such milk is dangerous for the infant and causes the disease. The 
poisons are probably toxins. They are excreted in greater quan- 
tities in the milk, if the mother is constipated. 6 

Bile. — Bile has been detected in the fat of the milk of a patient 
who developed jaundice after each confinement. The fat con- 
tained urobilin and small amounts of bilirubin, while there were no 
bile components in the aqueous liquid. 7 

1 Rotch: Pediatrics, Philadelphia and London, 1901, p. 144. 

2 Bendix: Charite-Ann., 1898, xxiii, 412. 

3 Finizio: Pediatria, 1908, vi, 401. 

4 Thiemich: Monatschr. f. Geburtsch. u. Gyn'ak., viii, 521; ix, 504. 
6 Guerrero and Cavieres: Bull. Manila Med. Soc, 1912, iv, 167. 

6 Inagaki and Nakayama: Abstr. in Brit. Jour. Dis. Child., 1910, vii, 467. 

7 Marck: Pharm. Weekblad., 1907, xliv, 153. 



116 DISEASES OF NUTRITION 

DIFFERENTIATION OF HUMAN FROM OTHER MILKS 

UmikofTs Reaction. — When 5 c. c. of milk are warmed on a 
water bath at 60 C. with 2.5 c. c. of a 10% solution of ammonium 
hydrate for from fifteen to twenty minutes, a reddish violet color 
appears if human milk is used, while there is no change with cow's 
milk. 

Davidsohn's Reaction. — See fat-splitting ferment. 

Moro's Reaction. 1 — Moro found that a 1% aqueous solution 
of neutral red turns human milk yellow and cow's milk purple. 
The addition of one drop of the stain to a teaspoonful of drawn 
breast-milk changes it to a reddish purple at once, if the milk has 
been kept too long and is unfit for use. 

Bauer's Reaction. 2 — Bauer found that the addition of one drop 
of a 0.25% aqueous solution of neutral blue sulphate (Grubler) to 
from 2 to 3 c. c. of human milk turns the milk violet-blue. When 
added to cow's milk it turns it greenish-blue. When about five 
times as much ether is added and the mixture is shaken violently, 
the color is extracted from human milk but persists in cow's 
milk. 

Tugendreich's Reaction. 3 — Equal amounts of a 1 to 2% 
aqueous solution of silver nitrate and milk are mixed, shaken and 
quickly boiled for three minutes. Human milk changes in color 
to coffee-brown or brownish-violet, while cow's milk does not. 

FERMENTS (ENZYMES) 

A great deal of importance has been attached to the ferments 
or enzymes of milk, especially in the discussions as to whether 
raw or boiled milk is the more digestible for infants and in con- 
nection with the diseases of metabolism, such as scorbutus and 
rachitis. 

The study of the ferments is open to error because of the presence 
of bacteria in milk. It is almost impossible to obtain a truly sterile 
milk and to keep that milk sterile for any length of time. The use 
of toluol or chloroform to keep the milk sterile may modify or 
destroy the enzymes, while sterilization by heat destroys the 
enzymes. Since the action of bacteria may cause all the phenomena 
produced by the ferments in milk, the action of bacteria must 
always be excluded. 

1 Moro: Miinchen. med. Wchnschr., 1912, lix, 2553. 

2 Bauer: Monatschr. f. Kinderh., 1912-13, orig. xi, 474. 

3 Tugendreich: Berl. klin. Wchnschr., 1911, xlviii, No. 1, p. 224. 



AND INFANT FEEDING 117 

The Proteolytic Ferments. — (a) Casease has the property of 
converting casein into soluble albumin. 1 It is found in human and 
cow's milk. 

(b) Pepsin and Trypsin : Both of these ferments are supposed to 
be present in cow's and human milk (Spolverini 2 ), the one acting 
in acid media and the other in alkaline surroundings. Other 
investigators 3 could not convince themselves that there were any 
such ferments in demonstrable quantities. The proteolytic fer- 
ments, according to Freeman 4 are not affected by heating for one- 
half hour at 65 C. (149 F.) or for one hour at 60 C. (140 F.). They 
are destroyed by boiling. 

(c) Fibrinogen : Schlossmann 5 observed that human milk 
caused the coagulation of the hydrocele fluid from a young in- 
fant, while cow's milk did not. This observation was sub- 
sequently confirmed. 6 It was shown that this ferment is not 
destroyed by heat 7 and that it is sometimes found in cow's 
milk. 8 

Carbohydrate-Splitting Ferments. — Amylase 9 has the power of 
splitting starch into dextrin and of continuing the process until a 
very little of it is converted into maltose. 10 This ferment is present 
in human milk. According to some investigators it is not present in 
cow's milk. Others 11 using different methods, always find it in 
cow's milk. The action of amylase is increased by the addition of 
peroxid of hydrogen. 12 It is destroyed at the temperature of 75 C. 
(167 F.), perhaps at a somewhat lower one. It appears to pass into 
the whey when the casein is precipitated. 

A disaccharid-splitting ferment has been reported in cow's milk 
which is capable of splitting lactose; it may also be present in 
human milk. 13 It is not changed by heating for one-half an hour at 
65 C. (149 F.) or for one hour at 60 C. (140 F.), but is weakened 

1 Raudnitz: Ergebn. d. Physiol., 1903, ii. 

2 Spolverini: Arch, de med. d. Enf., 1901, iv, 705. 

3 Moro: Jahrb. f. Kinderh., 1902, N. F., lvi, 391; Hippius: Jahrb. f. Kinderh., 
1905, lxi, 365. 

4 Freeman: Jour. Am. Med. Assn., 1907, xlix, 1740. 

5 Schlossmann : Verhandl. d. xviii Versamml. Gesellsch. f. Kinderh., Ham- 
burg, 1901. 

6 Moro: Wien. klin. Wchnschr., 1902, xv, 121. 

7 Moro and Hamburger: Wien. klin. Wchnschr., 1902, xv, 121. 

8 Bernheim-Karrer: Zentralbl. f. Bakt., 1902, xxxi, 388. 

9 Disatase, zymase, diastatic ferment. 

10 Bechamp: Compt. rend., Acad. d. sc, 1883, 96. 

11 Konig: Milchwirtschol: Zentralbl., 1907, iii. 

12 Lagane: Compt. rend., Acad. d. sc, 156, 1941. 

13 Stoklasa: Arch. f. Hyg., 1904, 1, 165. 



118 DISEASES OF NUTRITION 

by heating for a short time at 70 C. (158 F.) and is destroyed at 
75 C. (167 F.). 1 

Fat-Splitting Ferment. — This ferment decomposes neutral fats 
into fatty acids and glycerin. 2 It is found in both human and 
cow's milk. This ferment in human milk breaks tributyrin into 
butyric acid in a very few minutes, but in cow's milk only after 
many hours. This test may be used to differentiate raw human 
milk from boiled human milk, and raw and boiled cow's milk. 3 
The ferment is, therefore, present in relatively large amounts in 
human milk, but only in traces in cow's milk. Heating to 60 C. 
(140 F.) does not affect it, while 64 C. (147.2 F.) destroys it. 

Salol-Splitting Ferment. — It was found that human milk had 
the power of splitting salol. This power was not destroyed by 
heating to 100 C. (212 F.). Further investigation showed that this 
phenomenon was not due to a ferment, but was purely chemical. 
Salol is split in an alkaline medium of the same alkalinity as human 
milk. When cow's milk is brought to the same grade of alkalinity 
it also will split salol. 4 

Oxydase and Reductase. — (a) Superoxidase: Superoxidase is 
the name given to the ferment which reduces peroxid of hydrogen 
into water and oxygen. It acts best at about 37 C. (98.6 F.) and is 
destroyed at about 68 C. (154.4 F.). During centrifugalization it 
rises with the cream. 5 There is a large amount both in human milk 
and cow's milk. 

(b) Peroxidases: Peroxidases hasten the oxidation of such bodies 
as tincture of guaiac. They pass into the cream during centrifugali- 
zation and in fractional precipitation are precipitated along with 
the globulins. 6 There is no definite temperature at which this 
enzyme is destroyed, because the rate of heating modifies the 
results. 7 

(c) Reductase: When reductase comes in contact with sulphur 
and water it converts the sulphurin to the corresponding hydrids; 8 

1 Freeman: Jour. Am. Med. Assn., 1907, xliv, 1740. 

2 Marfan and Gillet: Monatschr. f. Kinderh., 1902-3, 1, 57; Moro (loc. cit. 
note 3); Hippius {loc. cit., page 117). 

3 Davidsohn: Ztschr. f. Kinderh., 1913, viii, 14. 

4 Demoulieres: Jour, de pharm. et chim., 1903, xvii; Miele and Willen: 
Compt. rend., Acad. d. sc, 1903, cxxxvii. 

5 Hecht and Friedjung: Arch. f. Kinderh., 1903, xxxvii, 177. 
6 Raundnitz: Pfaundler and Schlossmann: Diseases of Children, Philadel- 
phia and London, 1908, i, 308. 

7 Van Eck: Chem. Weckblad, viii, 692, ref. Chem. Abstr., Jan. 10, 1912. 
8 Rey: Pailhade quoted from Possi-Escot: Etat actuel sur les oxydases et 
reductases, Paris, 1902. 



AND INFANT FEEDING 119 

it also reduces methylene blue 1 and decolorizes Schardinger's 
reagent. 2 It is stronger in cream than in skimmed milk 2 and is 
precipitated with the casein. It is found in both human and cow's 
milk. Its action with Schardinger's reagent 3 is used in differen- 
tiating raw from boiled milk. Heating milk to between 70 C. 
(158 F.) and 80 C. (176 F.) stops the reaction. Reductase is most 
active between 40 C. (104 F.) and 55 C. (131 F.). 

TRANSMISSION OF TOXIC BODIES AND IMMUNITY THROUGH MILK 

Toxins. — Sonnenberger 4 concluded from his investigations that 
milk is not only a secretion but an excretion and that, therefore, 
many vegetable poisons in the food of animals may go over in 
the milk. Among these poisons are alkaloids, glycosids and 
amids, as well as volatile and ethereal oils, and dibasic organic 
acids. 

Toxins may be formed as the result of the metabolism of certain 
bacteria, may be produced by plants, or may come from the 
secretions or body components of certain animals. 

Antibodies. — Ehrlich 5 was the first to show that immunity 
could be transmitted to the infant through the milk. The fact that 
breast-fed infants seem to be less liable to such diseases as measles, 
scarlet fever, mumps and typhoid fever is used by many as an 
argument that immunity is transmitted through the breast- 
milk. 

Antitoxin. — It has been shown that in animals immunity to 
the bacillus of anthrax and the pneumococcus is transmitted by the 
mother to the young. It is impossible to say, however, whether 
this immunity is transmitted through the milk or is acquired during 
intrauterine life. 6 Ehrlich 5 concluded from his researches that 
artificial immunity can only come through the milk of the mother. 
When a mouse which was born of a normal mother, which was not 
immunized, was fed by a mouse immunized with antitoxin, the 
suckling developed immunity. The amount of antitoxin that 

1 Pozzi-Escot (see note 8, page 118). 

2 Smidt: Hyg. Rundschau, 1904, xiv, 1137; Hecht: Arch. f. Kinderh., 1904, 
xxxviii, 349. 

3 Five c. c. saturated alcohol solution of methylene blue, 5 c. c. formalin, 
190 c. c. water. 

4 Sonnenberger: Therap. Monatschr., 1901, xv, 6; Sonnenberger: lxxi Natur- 
forschersamml., Miinchen, 1899. 

5 Ehrlich: Ztschr. f. Hyg. u. Infectionskr., 1802, xii, 183. 

6 Chauveau: Ann. de l'lnst. Pasteur, 1888, ii, 66; Klemperer: Arch. f. Exper. 
Pathol, u. Pharm., 1892-93, xxxi, 356. 



120 DISEASES OF NUTRITION 

passes from the mother through the milk to the suckling is between 
one-fifteenth and one-thirtieth of the total amount in the mother, 
depending on the amount of lactalbumin and globulin that her 
milk contains. 1 It was impossible to immunize the human infant 
by feeding it with horse antitoxin, but when its own mother or the 
wet-nurse was immunized with horse antitoxin the immunity was 
transferred through the milk to the nursing infant even as early as 
the fourth week of life. 2 Immunity can, therefore, be transferred 
by way of the milk or albumins of the same species, but not by 
those of another species. 

Agglutinins. — The same question comes up in studying the 
agglutinins as in the case of the antitoxins as to whether the 
property of agglutination is acquired during intrauterine life or 
passes through the milk. 

The evidence that it may be transferred by the mother through 
her milk to the infant is in part positive and in part negative. 
Homer, 3 after summing up the literature, concludes that agglutinins 
may be transferred in the milk. The agglutinins in the milk of the 
mother are more easily absorbed from the infant's gastrointestinal 
canal than those in the milk of animals. 

Bactericidal Substances. — The fact that the blood of infants 
that are nursed at the breast contains stronger bactericidal sub- 
stances than that of those fed on the bottle 4 is evidence in favor of 
these substances being carried in the milk, in spite of the fact that 
they cannot be demonstrated in the milk itself. 

Hemolysin. — Hemolysin has recently been demonstrated as a 
normal constituent of the different kinds of milk. 5 It is absent 
from colostrum in the majority of cases tested on the second day 
postpartum. 6 Hemagglutinins are found in human milk that 
react differently toward the blood corpuscles of different species of 
animals. 7 

Opsonin. — The milk is poorer in opsonins than the blood serum 

iBrieger and Ehrlich: Ztschr. f. Hyg., 1893, xiii, 336; Brieger and Cohn: 
Ztschr. f. Hyg., 1893, xv, 1; Wassermann: Ztschr. f. Hyg., xviii; Ehrlich and 
Wassermann: Ztschr. f. Hyg., 1894, xviii, 235; Romer: Berl. klin. Wochenschr., 
1901, xlvi, 209; Kayser: Ztschr. f. klin. Med., 1905, lvi, 17. 

2 Salge: Jahrb. f. Kinderh., 1904, lx, 1. 

3 Romer: Sommerf eld's Handbuch der Milchkunde, Wiesbaden, 1909, 
492. 

4 More-: Jahrb. f. Kinderh., 1902, lv, 396. 

5 Pfaundler and Moro: Ztschr. f. Exper. Pathol, u. Therap., 1907, iv, 
451. 

6 Kolff and Noeggerath: Jahrb. f. Kinderh., 1909, Ixx, 701. 

7 Zubezycki and Wolfsgruber: Deutsch. med. Wochenschr., 1913, xxxix, 210. 






AND INFANT FEEDING 121 

of the mother 1 while the colostrum contains more than the 
milk. 2 

Hypersensibility. — Hypersensibility (sensitization) toward va- 
rious poisons and albumins may pass over in the milk to the infant 
and be absorbed. 3 

1 Turton and Appleton: Reference, Deutsch. med. Wochenschr., 1907, xxxiv. 

2 Tunnicliff : Jour. Infect. Dis., 1912, xi, 347. 

3 Otto: Mtinchen. med. Wochenschr., 1907, liv, 1665. 



122 DISEASES OF NUTRITION 



CHAPTER XI 
CLINICAL CONSIDERATIONS AND TECHNIQUE 

The contraindications to nursing have already been mentioned, 
and the ability of women in general to nurse their babies has al- 
ready been referred to. Far more women are able to nurse their 
babies than is generally supposed. As a matter of fact, very few 
women are entirely unable to nurse. The so-called inability to 
nurse is in many instances unwillingness rather than inability. 
Many women are, however, thought to be unable to nurse when 
they really are able. The attempt at nursing is not infrequently 
given up too soon because the milk is late in appearing. The 
production of milk begins in two ways : either the quantity of milk 
slowly, but gradually, increases or, after a very small secretion in 
the beginning, there is a very sudden increase, which is often 
spoken of as the "running-in" of the milk. The supply of milk is 
often considered insufficient when the "running-in" is delayed, and 
breast feeding is therefore considered impossible. Dluski's fig- 
ures 1 show how different the time of the "running-in" of the 
milk may be. She found that in 326 primiparse the running-in 
of the milk occurred as follows: 9 times after 24 to 48 hours, 115 
times after 48 to 72 hours, 159 times after 72 to 96 hours, 42 times 
after 96 to 120 hours, one time after 120 to 144 hours. The best 
method of hastening the appearance of the milk is by emptying 
the breasts as completely as possible. The best way to do this 
is by putting an older and stronger infant to the breast. The older 
infant not only sucks more strongly, but does not get as tired as the 
younger child, who often refuses to nurse after a few attempts, if 
the milk does not flow easily. If an older baby cannot be obtained, 
the mother's own infant may be used. 

The supply of milk is not infrequently insufficient while the 
mother is in bed, and nursing is on this account given up. It is not 
uncommon, however, to have the supply of milk increase and be 
amply sufficient after the mother is able to be out of bed and to take 
up her ordinary routine. 

It is sometimes thought that it is not worth while for a woman to 
nurse her baby unless she can nurse it for a considerable time. 

1 These de Paris, 1894. 



AND INFANT FEEDING 123 

This belief is, of course, entirely erroneous, because there is no time 
in a baby's life at which it is more important for it to have breast- 
milk than in the beginning. There is no time at which a baby's 
digestion is so easily disturbed and so hard to correct, if disturbed, 
as in the early days and weeks of life. Every day or week that a 
baby gets breast-milk gives it a better start and makes it easier to 
put it on an artificial food later, if it is necessary. It is also some- 
times thought that it is hardly worth while to give a baby the 
breast, unless it can get all its food from the breast. Others believe 
that it is dangerous to mix human milk and artificial food. This 
belief is, of course, entirely erroneous. The artificial food cannot 
make the breast-milk harder of digestion, while the breast-milk 
clinically certainly seems to make the digestion of the artificial 
food easier. Every little bit of breast-milk helps the baby and 
makes it easier to feed it artificially. This may be due in part to the 
ferments which the breast-milk contains, but more probably is due 
to the fact that the baby is able to utilize the proteins of human 
milk to build tissues, when it is not able to utilize the proteins of the 
artificial food in the same way. 

Nursing is sometimes given up almost at once because of poor 
nipples or cracked nipples. Nursing should not be given up for 
these reasons until strenuous attempts have been made to draw out 
the nipples or to have the baby nurse with a nipple-shield. Cracked 
nipples will almost invariably heal if time and trouble enough are 
taken. 

In other cases nursing is not attempted because it is feared that 
the strain of nursing will be too great for the health of the mother. 
It is true that in some instances nursing does pull down the mother 
materially. It must not be forgotten, however, that nursing is a 
physiological and not a pathological condition, and that many 
women are better while nursing than at any other time. Even if it 
does pull a woman down, however, a mother should be willing to 
sacrifice herself to a certain extent in order to give the baby a good 
start. A few weeks or a few months of nursing will make all the 
difference to the baby in the future. It is often said that women are 
too nervous to nurse, that their milk will be bad on this account 
and that the baby will be disturbed and will not thrive. This is 
undoubtedly true in a certain number of instances. Other women, 
however, apparently as unsuitable for nursing, prove to be very 
good nurses. On this account, therefore, nursing should always be 
attempted, to be given up later if it is not successful. 

In general, women are altogether too prone to believe on in- 
sufficient grounds that they cannot nurse their babies. It is sad to 



124 DISEASES OF NUTRITION 

say that they are often aided and abetted in this belief by physi- 
cians and nurses, who should know better. It is a hopeful fact, 
however, that the women among the well-to-do and educated 
classes are beginning to appreciate the importance of breast feeding 
and that many more of them are not only willing but anxious to 
nurse than were a few years ago. 

Feeding in the First Few Days of Life. — The baby should 
be put to the breast from six to twelve hours after birth, according 
to the condition of the mother and the strength of the baby. The 
object of putting the baby to the breast at this time is not to give 
the baby food, but to stimulate the breast to secretion. It is 
supposed that nursing also favors the involution of the uterus. 
There is, however, no positive proof that this is so. The baby 
should be put to the breast every six hours during the next twenty- 
four hours, and every four hours during the succeeding twenty- 
four hours. With the appearance of the milk, the interval may 
then be shortened. The average amount of colostrum obtained 
during the first twenty-four hours is from 4 to 6 c. c, and during 
the second twenty-four hours, 90 c. c. In the majority of cases the 
milk then comes in rapidly on the third and fourth days. In many 
instances, however, the milk does not come in until a day or two 
later than this. It is evident from the small amount of colostrum 
secreted during the first two or three days that the baby is not 
intended by nature to get much food during this time. Further 
proof of this fact is that the initial loss of weight is not prevented 
by feeding larger amounts of food from the beginning. It is well, 
however, to give the baby water freely in order to flush out the 
kidneys and make up for the water lost in other ways. One or two 
drachms should be given every two hours, more often if the baby 
wishes it and will take it. It is often advisable to give a solution of 
milk sugar and water at this time in order to favor the development 
of the normal bacterial flora. There is no proof, however, as to 
whether this is accomplished or not. Some believe that sugar at 
this time does harm, but there is no proof whether it does or not. 
It is probably, however, better on the whole to give a mixture of 
saccharin and water than sugar and water. 

Most babies begin to show signs of hunger after the first forty- 
eight hours. It must be remembered, however, that crying at this 
time does not necessarily mean hunger, because every new-born 
baby cries a certain amount. It is wiser to begin to give some food 
on the third day, if the supply of breast-milk is insufficient. It is 
not necessary to begin to feed them at this time, however, as 
experience has shown conclusively that it does the baby no harm 



AND INFANT FEEDING 125 

to go four or five days without food. It is very important, when 
beginning to feed a new-born baby, not to give it too much food 
or too strong a food. There is no time in a baby's life in which it is 
so easy to disturb the digestion or at which it is so difficult to cor- 
rect the disturbance, if it is once caused. If the baby is put to a 
breast whose secretion is already established, there is great danger 
that it will take too much food and be disturbed by it. The dura- 
tion of nursing must, therefore, be very short in the beginning. It 
is often wiser to give breast-milk diluted with water from a bottle 
for one or two days before putting the baby to the breast. It 
is probable, too, that the baby digests breast-milk better if 
it has had colostrum first. There is, however, no proof of 
this. 

If the baby has to be given an artificial food, it is very important 
not to give it too strong a mixture. It is absolutely wrong to say, as 
many physicians do, "Give it a little milk and water. It is not 
necessary to give it a mixture at this time, because it will be on the 
breast in a few days." The digestion is so easily disturbed at this 
time that there is no time at which it is more important to give a 
mixture suited to the baby. It is very important to begin with a 
weak mixture and to give it in small amounts. If this mixture is 
digested and the baby is still hungry, it is very easy to increase 
the strength and the amount of the food. If the baby is upset by 
too strong a food, it is a very difficult matter to correct the dis- 
turbance. The mixture should be low in fat and proteins, which are 
relatively hard to digest, and proportionally high in sugar, which is 
easy of digestion at this time. It is wise, also, to give a part of the 
proteins in the form of the whey proteins. A suitable mixture is 
fat 1%, milk sugar 5%, whey proteins 0.25%, casein 0.25%. This 
may be quickly strengthened, perhaps in the first twenty-four 
hours to fat 1.50%, sugar 6%, whey proteins 0.50%, casein 0.25%, 
and then in another twenty-four hours to fat 2%, sugar 6%, whey 
proteins 0.75% and casein 0.25%. Two drachms (10 c. c.) is enough 
at first. This can be quickly increased to one-half to one ounce 
(15 or 30 c. c). 

The colostrum is supposed to have a laxative action. Such an 
action, however, has not been proven. If the bowels have not 
moved well during birth or during the first twenty-four hours, it is 
wise to give a teaspoonful of castor oil in order to empty them, 
because of the possible danger of the absorption of the products of 
decomposition of retained meconium. It is probable that these 
products may cause convulsions and other severe nervous symp- 
toms, as well as fever and marked prostration. At any rate, such 



126 DISEASES OF NUTRITION 

symptoms in the new-born are repeatedly relieved by the emptying 
of the intestinal tract. 1 

Intervals between Nursings. — There is much difference of 
opinion as to the proper intervals between nursings. This subject 
will be discussed later in detail in the chapter on artificial feeding. 

Regularity of Nursing. — Whatever intervals between nursings 
are adopted, the baby should be nursed regularly at these intervals. 
There is, of course, no doubt that many babies thrive in spite of 
being nursed at any and all times. On the average, however, babies 
do better when they are fed regularly. A baby quickly accommo- 
dates itself to being fed at regular intervals and soon learns to 
expect to be fed at these times and not at others. The mother, 
moreover, can arrange her time much better, if she knows when the 
baby is to be fed. It is very difficult for the modern woman, who 
has many other legitimate demands upon her time, to always be 
on hand at the nursing time. One bottle feeding a day makes it 
much easier for many women and enables them to nurse their 
babies when they would otherwise not be able to do so. An addi- 
tional advantage in one bottle feeding a day is that the baby 
becomes accustomed to the bottle and weaning is, therefore, much 
easier when it becomes necessary. It is especially pernicious to 
nurse the baby off and on all night. If this is done, the sleep of 
both mother and baby is disturbed and they suffer, the mother the 
more, from the loss of sleep. A baby should not be nursed more 
than once in the night, and this nursing should be stopped when 
the baby is a few weeks old. 

Waking to Nurse. — It is claimed by some authorities that 
a baby should not be waked to nurse, but should be allowed to sleep 
as long as it desires and nurse when it awakens, the only rule as to 
the length of the interval between nursings being that it shall not be 
less than 2 hours, so as to avoid feeding before the stomach is 
empty. There is no doubt that babies will thrive on this system of 
breast feeding, as they will on almost any scheme of breast feeding. 
This method is, however, not suited to the exigencies of modern 
life. Most women have to arrange their time systematically in 
order to fill all their engagements and cannot wait, therefore, on the 
baby's convenience. It is much wiser, on the whole, to wake the 
baby at the proper time. A normal baby that is fed regularly 
wakes in most instances at regular intervals and, in any case, will 
quickly go to sleep again after being nursed. 

Alternate Breasts. — If the supply of milk is sufficient, it is 
usually advisable to give the breasts alternately. By this method 
1 Morse: Amer. Journal of Diseases of Children, 1912, iv, 229. 



AND INFANT FEEDING 127 

the breasts are more thoroughly emptied and the production of 
milk is encouraged. If both are given at the same time, they are 
not emptied and the production of milk is discouraged. There is, 
moreover, a tendency to reversion to the colostrum stage. If the 
supply of milk is insufficient, it is advisable to give both breasts at 
each feeding. The baby in this way gets a sufficient amount of 
food, the breasts are emptied and the production of milk is en- 
couraged. 

Duration of Single Nursing. — If the supply of milk is abundant 
and the baby well and vigorous, it will usually occupy about 
twenty minutes in nursing. Many normal babies will, however, 
take only ten or fifteen minutes in nursing. The time taken in 
nursing varies according to the sucking strength of the baby, the 
amount of milk in the breasts, and whether the breast is one which 
it is hard or easy to empty. It must be remembered in this connec- 
tion that the milk flows most freely at the beginning of a nursing, 
and that the amount obtained diminishes progressively with the 
duration of the nursing. The baby gets more than one-half of the 
meal in the first five minutes, more than one-quarter in the next 
five minutes, and but comparatively little after this. x If the baby 
nurses more than thirty minutes there is something wrong. The 
trouble may be that the supply of milk is insufficient, or that the 
baby is too feeble to nurse vigorously and continuously. The 
baby should not drop off to sleep while nursing. If it does, it 
means that the supply is insufficient and he gives up after getting 
a little, that he is not hungry and that the intervals should there- 
fore be lengthened, or that he is feeble or sick in some way. While 
the supply of milk is greatest at the beginning of the nursing, 
the strength of the milk increases progressively throughout the 
nursing, the total solids being greater at the end than at the 
beginning of a nursing. This difference is, however, not great 
enough to be of much practical importance. 

Amount Taken at Each Nursing — The amount taken at a 
nursing varies materially from nursing to nursing and bears no 
relation to the theoretical size of the stomach. A baby will take 
two ounces at one feeding, and six ounces at the next, and so on. 
A baby three weeks old will sometimes take as much as six ounces 
at a nursing, and one of two months as much as eight ounces at a 
nursing, and so on. The amount taken in twenty-four hours will, 
however, be approximately the same from day to day, increasing, 
of course, with the age of the baby. 2 Variations in the amount of 

1 Feer: Jahrbuch f. Kinderheilkunde, 1896, xlii, 195. 

2 Peters: Archiv. f. Kinderheilkunde, 1902, xxxiii, 295. 



128 DISEASES OF NUTRITION 

fat in the milk do, however, influence the total amount taken in 
twenty-four hours, less being taken when the percentage of fat 
is high. The explanation of the difference in the amount taken at 
different feedings is probably either that there is a variation in the 
supply of milk or that the baby is not as hungry at one time as at 
another. If it has taken a large amount at one feeding, it will 
naturally not take as much at the next and vice versa. The 
explanation of the fact that a baby can take an amount at a single 
nursing far in excess of its gastric capacity is that the milk passes 
directly into the duodenum, even during the act of nursing. 

Difficulty in Technique of Nursing. — If a baby does not nurse 
well, the trouble may be with the baby or with the mother. If the 
trouble is with the baby, it may be some deformity of the lips or 
mouth, nasal obstruction from adenoids or some other cause, which 
interferes with nursing, or weakness. Older babies that have been 
fed on the bottle are often unwilling to take the breast, because 
they are unaccustomed to it. Babies that are partly bottle and 
partly breast-fed will often refuse the breast because they have to 
work harder to get the milk from the breast than they do to get it 
from the bottle. 

Retracted or small nipples are the most common cause of 
difficulty in nursing on the part of the mother. In rare instances 
the nipples are too large. Cracked nipples also frequently interfere 
with satisfactory nursing. Many mothers do not know how to 
hold a baby to make it comfortable while nursing. Other mothers, 
through nervousness, disturb the baby and prevent it from taking 
hold and nursing satisfactorily. 

Treatment. — Deformities of the mouth and lips must be cor- 
rected. In general, it is not wise to operate on a hare-lip until the 
baby is at least six weeks old, or on a cleft-palate until it is at least 
six months old. The baby can be fed with breast-milk by means of 
a dropper, spoon, Breck feeder or tube in the meantime. Adenoids 
should be removed at once if they cause interference with nursing, 
no matter how young the baby may be. Feeble babies can be fed 
wholly or in part in the same ways as those with deformities of the 
mouth and lips. Babies that are unwilling to take the breast can 
usually be starved to it. Putting sugar on the nipples, pressing 
some of the milk into their mouths at the beginning of nursing, or 
the use of a nipple-shield will sometimes induce them to take hold. 
They will sometimes nurse in the dark or when blindfolded, when 
they will not otherwise. 

Care of the Nipples. — Something can be done during pregnancy 
to bring out retracted nipples by manipulation, careful application 



AND INFANT FEEDING 129 

of a breast-pump and sucking. The nipples should be carefully 
washed and cleaned during the latter days of pregnancy in order to 
remove the excess of epithelium and to clear the openings of the 
ducts. 

The nipples should be washed before and after each nursing with 
sterile water or with a saturated solution of boracic acid and 
thoroughly, but carefully, dried with a soft cloth or absorbent 
cotton. It is wise to protect them with a cloth moistened with 
albolene or boracic acid ointment between the nursings. If the 
nipples are tender they may be washed with a 50% solution of 
alcohol. If the nipples become cracked, the baby should not be 
allowed to nurse, except through a nipple-shield. If it does not 
thoroughly empty the breasts in this way, they should be emptied 
by massage or a breast-pump. Cleanliness and a simple ointment, 
like boracic acid ointment, are usually sufficient to heal them. 
In some instances, however, it is necessary to touch the cracks with 
a 1% or 2% solution of nitrate of silver. If the breasts are full or 
tender, they should be supported with a breast-binder and kept 
empty by massage and a breast-pump. It is safer, as a rule, to take 
the baby off of an inflamed breast and empty the breast by mas- 
sage or with a breast-pump. If the milk contains no pus corpuscles 
there is probably, however, no risk to the baby, if the nursing is 
continued. 

Breast-Pumps and Nipple-Shields. — The so-called English 
breast-pump is the most satisfactory. The glass nipple-shields 
with a rubber nipple are the best. A baby will often nurse better 
from a shield if it is first filled with milk. 

Care of Baby's Mouth. — There is always danger of infection 
of the nipples and breast from the baby's mouth, if it is not kept 
clean. The condition of the baby's mouth must, therefore, be 
watched. It is far more likely to become inflamed and infected, if 
it is washed than if it is left alone. The baby's mouth should, 
therefore, not be washed. A swallow of water after nursing is all 
that is necessary. 

Method of Nursing Baby. — The baby should be held lying 
on its side with its head a little elevated. It must be everywhere 
supported, so that it is relaxed and comfortable. The breast above 
the nipple must be pressed away from its nose, so that it can 
breathe freely. The mother and attendants must be quiet and 
composed. Otherwise the baby is disturbed and excited and will 
not nurse well. 

Not all Human Milk is Good Milk. — Everyone agrees that 
human milk is the best food for infants. It is equally true, however, 



130 DISEASES OF NUTRITION 

that not all human milk is good milk. Some milks will not agree 
with any baby. Other milks will agree with one baby and not with 
another. A milk which suits one baby will not suit another, and 
what suits the second baby will not suit the first baby. It is im- 
possible to determine from an analysis of a milk whether it will or 
will not agree with a given baby. This can only be told by expe- 
rience. Babies will often thrive on a milk which would, from its 
analysis, seem most unsuitable. The same baby will often thrive 
on different types of milk. While it is impossible to determine 
from an analysis of the milk whether it will or will not agree with a 
baby, it is, however, often possible, if a milk is not agreeing with a 
baby, to tell from the analysis why it does not. If a milk does not 
agree with a baby, the most common abnormality in the milk is an 
excessive amount of proteins. The next most common abnormality 
is an excess of fat. There is very seldom an excess of sugar. 

Types of Abnormal Milk. — Human milk may be unsuitable 
or abnormal in many ways. Three general types can be recognized. 

(1) All elements too high. 

(2) Fat and sugar low, proteins high. 

(3) Fat and sugar very low, proteins very high. 

The first type is most often found in indolent women of the 
wealthy classes, who, being blessed with a good digestion, eat too 
much and too rich food. An example of such a milk is the following 

Fat 5.00% 

Sugar 7.50% 

Proteins 2.60% 

There is no difficulty in correcting this type of milk, provided the 
woman will eat properly and take exercise. It is, however, un- 
fortunately rather hard to induce such women to change their 
habits. 

The second type is most often found in women of the poorer 
classes who are compelled to work hard and do not have sufficient 
food. It is, in fact, a starvation milk. A typical analysis of such a 
milk is 

Fat 1.75% 

Sugar 4.50% 

Proteins 2.50% 

This type of milk is also easily changed by giving sufficient food 
and diminishing the work. Unfortunately, it is, in this instance 
also, difficult to remedy the underlying social conditions. 



AND INFANT FEEDING 131 

The third type is usually found in the highly-strung, over- 
educated and highly-civilized women of the large cities, but may be 
found in neurotic women of any class or community. A char- 
acteristic analysis of this type of milk is 

Fat 1.00% 

Sugar 4.00% 

Proteins 3.75% 

It is practically impossible to modify this type of milk, because it is 
impossible to change the fundamental abnormality of the woman's 
nervous make-up. 

Analysis of Breast-Milk. — Too much reliance must not be 
placed on an analysis of the breast-milk, because the composition 
of milk varies in the same woman from day to day and from nursing 
to nursing. It also differs at different periods of the same nursing. 
An analysis is valueless, therefore, unless all the milk is taken from 
the breast, or at least samples from the beginning, the middle and 
the end of the nursing. The results of a single examination, even if 
the milk is properly taken, may also be misleading, because of the 
variation from day to day and nursing to nursing. Positive 
conclusions can be drawn only when the results of several examina- 
tions are similar. 

The Normal Breast-Fed Infant. — A baby that is thriving on 
the breast should gain from six to eight ounces a week during the 
first five months, and from four to six ounces a week during the 
rest of the first year. Smaller but steady gains are, however, not 
necessarily abnormal. It should double its birth weight in the 
first five months, and treble it at the end of the first year, or a little 
later. It should have from two to four smooth, orange-yellow 
stools of the consistency of thick pea-soup daily during the first few 
months, and from one to three similar stools of somewhat greater 
consistency during the rest of the first year. It should not vomit 
unless it is disturbed or shaken up soon after a feeding. It should 
not cry unless hungry or when uncomfortable from wet diapers, 
wrinkles in its clothing, and so on. Its flesh should be hard and 
firm, its lips, cheeks and nails pink. It should sleep from twenty to 
twenty-two hours out of the twenty-four during the first two 
months, and about sixteen hours a day during the latter half of 
the year. It should be happy when awake, active when given the 
opportunity. 

Theoretically the normal baby should gain regularly every day 
and should never lose. Practically this never happens. The baby 
gains one day, remains stationary another day and loses on a third, 



132 DISEASES OF NUTRITION 

there being, however, a steady gain from week to week. Very- 
few babies, however, get through the year without, for some reason, 
which may or may not be apparent, failing to gain or lose for one or 
more weeks. 

Many babies that are gaining regularly and apparently thriving 
in every way on the breast have abnormal stools. The attempt 
should be made to correct these stools by modification of the milk 
through regulation of the mother's diet and life. The baby should 
not be taken off the breast, however, even if the attempt is un- 
successful. A baby that is gaining and thriving in other ways 
should never be weaned simply because the stools are abnormal, no 
matter how abnormal they may be. Many a baby has been in- 
jured, and not a few killed, by being taken off the breast on this 
account. It must never be forgotten that stools which in the 
artificially-fed baby mean serious disturbance of the digestion and 
demand prompt modification of the food can be practically dis- 
regarded in the breast-fed, provided the babies are thriving in 
other respects. 

The Abnormal Breast-Fed Infant. — When a breast-fed baby, 
which is not gaining properly, has one or more normal stools daily 
it is almost certain that the failure to gain is not due to any defect 
in the quantity or quality of the milk. The source of the trouble 
must be sought elsewhere. It will then be found that the baby is 
being improperly handled in some way or that it has some disease. 
It may be that it is excited too much, that it does not get enough 
sleep, that it does not get enough fresh air, or that it is not kept 
warm enough. Hidden tuberculosis, pyelitis and an insufficient 
supply of air as the result of adenoids are frequent causes of failure 
to gain. 

Failure to gain in weight may or may not be associated with 
symptoms of disturbance of the digestion. 

If there are no symptoms of disturbance of the digestion and 
the baby is constipated, as it usually is, the food is deficient in 
quantity, quality, or both. If the supply of food is sufficient to 
supply the pangs of hunger, the baby will not appear hungry, even 
if the food is entirely inadequate to enable it to gain in weight. 

The only way to determine how much milk a baby is getting 
from the breast is to weigh it before and after each nursing for 
twenty-four hours. The difference in weight shows the amount of 
milk taken, as an ounce of milk weighs practically one ounce 
avoirdupois. It is not sufficient to weigh the baby before and 
after one or two nursings, because of the difference in the amount of 
milk taken at different nursings. The total amount taken in 



AND INFANT FEEDING 133 

twenty-four hours must always be determined. It is, of course, 
unnecessary to undress the baby in order to weigh it. If the baby 
is restless and it is hard to weigh it accurately, the same result can 
be obtained by weighing the mother before and after nursing. 
What she loses represents, of course, the amount of milk taken by 
the baby. 

Other methods of estimating the amount of milk are very unre- 
liable. It is impossible to tell the amount of milk from the size of 
the breasts. Many large breasts secrete but little milk, while 
other small breasts secrete a considerable amount of milk. It is 
impossible, also, to determine the amount of milk by attempting to 
express it or by taking it out with a breast-pump, because a baby 
will often get a large amount of milk from the breast when but little 
or nothing can be obtained by expression or with a pump. Evi- 
dence of considerable importance in favor of an insufficient supply 
of milk is when a baby wakes up hungry some time before every 
feeding. Other suggestive evidence is when a baby drops the 
nipple during the feeding and cries with anger, or when it grabs the 
nipple and shakes it as a puppy does a root. 

The quality of the milk can only be determined by chemical 
analysis. Great care must be exercised, however, in the interpreta- 
tion of the findings of such an analysis, as has already been ex- 
plained. Under these conditions the milk is usually weak in all its 
constituents, or the percentage of fat is very low, while the other 
elements are approximately normal. 

When there are symptoms of a disturbance of the digestion, 
there is either an excessive amount of milk or the quality of the milk 
is abnormal. When there is an excessive amount of milk the baby 
usually vomits, especially soon after nursing, and has too many 
stools, which, in most instances, are in some way abnormal. The 
quantity of the milk can only be positively determined, however, 
by weighing the baby or the mother before and after each nursing 
for at least twenty-four hours. Abnormalities in the composition 
of the milk are shown by colic, vomiting and abnormal stools. The 
abnormality is usually an excess of fat or proteins, more often of 
proteins, rarely of sugar. An excess of fat is shown in most in- 
stances by the presence of small, soft curds in the stools, the typical 
soap stool being unusual in the breast-fed baby. When there is 
an excess of proteins, the stools are likely to be watery, to be some- 
what brownish in color and to contain mucus. They are often 
greenish and frequently contain mucus when the milk is abnormal 
in any way, but the typical, green, fermented, irritating stool of an 
excessive amount of sugar is seldom seen. The only way in which 



134 DISEASES OF NUTRITION 

the error in the composition of the milk can be accurately deter- 
mined, however, is by chemical analysis of the milk, due regard 
being paid to the possibilities of mistakes in drawing conclusions 
from such analyses. 

Modification of Breast-Milk. — The secretion of breast-milk 
and the various factors which influence it have been discussed in a 
previous chapter. It will perhaps be well, nevertheless, to review 
the subject from the clinical standpoint. In the first place, lacta- 
tion is, or should be, a physiological, not a pathological process. 
A nursing woman is in a normal, not an abnormal, condition. 
She should, therefore, lead the same sort of life when she is nursing 
that she does when she is not nursing, provided her manner of 
living is a normal one. In view of the fact that there is a certain 
amount of additional strain in nursing, she should be careful not to 
overdo or to get overfatigued. Her diet should be that to which 
she is accustomed when she is not nursing. There is no reason why 
she should not eat anything which does not disturb her digestion, 
but should, as when not nursing, avoid articles of food which dis- 
agree with her. There is very little in the old theory that a nursing 
woman should avoid certain fruits and vegetables because they will 
disturb the baby's digestion. It is true that sometimes when a 
given woman eats a given thing the baby will be disturbed. It is 
impossible to tell in advance, however, what this thing will be. 
Moreover, the thing which causes disturbance in one instance will 
not cause disturbance in the next, while something else will. A 
nursing woman should, therefore, eat a general diet, avoiding 
articles of food which disturb her digestion. If her baby is upset, 
she should try to remember what unusual article of food she has 
eaten. If the baby is upset when she eats it again, she should 
avoid it in the future. 

Modification of Quantity of Breast-Milk. — In the first place, 
it must be remembered that Nature tends to accommodate the 
supply of breast-milk to the demand. If but little is taken, little 
will be produced. If much is taken, much will be produced. The 
best stimulant to the secretion of milk is the thorough emptying of 
the breast. There is nothing else which tends to increase the 
quantity so much. The next best stimulants to the secretion of 
milk are a liberal, general diet and a normal life. Increasing the 
quantity of liquid in the diet increases the quantity of milk to a 
certain extent. It is useless, however, for a woman to take more 
than a quart of extra liquid daily. More than this either disturbs 
her digestion or makes her grow fat. This extra liquid should 
not be too rich. It is given chiefly for its action as a liquid, not as a 



AND INFANT FEEDING 135 

food. If it is given in the form of chocolate, eggnogs, and things of 
like nature, it takes away the appetite for solid food, and the 
total ingestion of food is not only not increased but often dimin- 
ished. Milk and cocoa shells are probably the best drinks. Gruels 
seem to have a certain action as galactagogues. So do malt liquors 
in some instances. It is better not to use them as a rule, however, 
because they are likely to disturb the digestion and fatten the 
mother. There is no danger to the baby from their alcoholic 
content. There are no drugs which, whether taken internally or 
applied externally, can increase the flow of milk to any appreciable 
extent. 

It is seldom necessary to diminish the quantity of milk. Diminu- 
tion in the amount of food and liquid ingested will usually speedily 
diminish the supply of milk. Moreover, if the breasts are not 
thoroughly emptied, Nature will quickly reduce the supply. 
External applications are usually not efficacious and always in- 
advisable. The bowels may be opened freely, if necessary, to re- 
duce the amount of milk temporarily. 

Modification of Quality of Breast-Milk. — When the total solids 
of the milk are all high, as the result of overeating and lack of 
exercise, they can be reduced by regulation of the diet and exercise. 
When they are low, as the result of starvation and malnutrition, 
they can be increased by proper food and care. They can also be 
influenced to a certain extent by varying the intervals between 
nursings. Lengthening the intervals diminishes the total solids; 
shortening the intervals increases them. 

It has been taught for many years that the amount of fat in 
the milk varies directly with the amount of protein in the food. 
This teaching is, however, erroneous, the only way in which the 
protein in the food can increase the fat in the milk being by im- 
proving the general condition. The amount of fat in the food has 
but little influence on the amount of fat in the milk. If the mother 
is underfed, an increase in the fat in the food will temporarily result 
in an increase in the fat in the milk. If she is not underfed, an 
increase in the fat in the food does not increase the fat in the milk. 
An excessive amount of fat in the milk is most often due to an 
excessive amount of food in general rather than to an excess of any 
one element and can be diminished best by cutting down the food 
as a whole. An insufficient amount of fat in the milk is usually due 
to malnutrition. It can be increased by building up the general 
condition by increasing the supply of food and regulation of the 
life. An increase in the amount of fat in the food will also some- 
times temporarily cause an increase in the percentage of fat in the 



136 DISEASES OF NUTRITION 

milk. When a breast-milk is low in fat, but otherwise of good 
quality, it is easy to make up for the deficiency of fat by giving 
the baby cream with the nursings. Enough cream should be given 
to bring the percentage of fat to the proper level. For example, 
if a baby is taking four ounces of breast-milk, containing 1% of fat, 
the addition of one-half ounce of gravity cream will raise the per- 
centage of fat to three. The cream may be given before or after 
the nursing, but is best given in the middle of the nursing. A very 
good way to give it is from a dropper introduced into the mouth 
beside the nipple while the baby is nursing. 

The percentage of the sugar in the milk cannot be directly 
influenced in any way. It tends to vary directly with the general 
condition of the mother. 

The percentage of protein in the milk cannot be influenced by 
diet. The most common cause of an excessive amount of protein is 
nervousness. If the mother's nervous condition can be quieted, 
the percentage of protein will diminish. The amount of protein 
can also be diminished by exercise, but if the exercise is excessive 
and causes fatigue, the protein will be increased. In many cases, 
therefore, when the woman is overtired, the protein can be dimin- 
ished by rest. 

Mixed Feeding. — When a woman does not have sufficient milk 
to satisfy her baby, the baby should not be weaned, but should 
be given an artificial food in addition to the breast-milk. If the 
supply of milk is almost sufficient, the baby may be given the 
artificial food entirely at one or at two feedings and the breast at 
the others. It is hardly ever advisable to omit more than two nurs- 
ings, because the supply of milk is likely to diminish still further 
from lack of stimulation of the breasts, if more than this number 
of feedings are omitted. If there is much deficiency in the supply, 
the breast should be given at each feeding, followed by an artificial 
food. The amount of artificial food to be given depends, of course, 
on the amount of breast-milk. This is best determined by weighing 
the baby or mother before and after nursing and giving enough 
artificial food to make up the proper amount for a feeding. It is 
usually not necessary to weigh the baby before and after every 
feeding, once the average amount obtained from the breast has 
been ascertained. 

No attempt should be made, in deciding on the composition of 
the artificial food, to imitate the composition of the breast-milk. 
The fact that the baby can digest human milk of a given composi- 
tion does not indicate at all that it can digest a cow's milk mixture 
of the same composition, because, although the percentages of the 



AND INFANT FEEDING 137 

components of the two foods may be the same, the foods are 
different. One is human milk; the other is cow's milk, in spite of 
the fact that it is modified. The composition of the artificial food 
should be decided on general principles, based on the age and 
apparent digestive capacity of the infant. An analysis of the 
breast-milk is, however, sometimes of assistance in determining 
what shall be the composition of the artificial food, because in some 
instances, in which there is a deficiency of some element in the 
breast-milk, it can be corrected by an increase in the amount of this 
element in the artificial food. 

Weaning. — A baby should not be taken off the breast unless 
there is a good reason for so doing. A baby should not be weaned 
during the early weeks of life, on the ground that the milk is 
unsuitable, simply because the baby has the colic and abnormal 
stools. It is wiser to wait until the mother is out of bed and has 
resumed her usual mode of life before deciding that the milk will 
not agree, because in many instances the symptoms of indigestion 
cease and the baby begins to thrive as soon as the mother gets back 
to her normal routine. It is important, on the other hand, not to 
wait too long and allow the digestion to get thoroughly upset before 
weaning. A baby should not be weaned hastily on account of 
cracked nipples. These can almost always be cured and the nurs- 
ing continued. 

A baby should not be weaned because of the appearance of 
menstruation. As a matter of fact, more women menstruate dur- 
ing the period of lactation than do not. In most cases the baby 
shows no evidences of disturbance of digestion during the men- 
struation; in some, the baby ceases to gain during this time and has 
the colic or undigested stools. A very few are seriously disturbed. 
They should not be weaned, however, but should be given an 
artificial food while the menstruation lasts and put back on the 
breast as soon as it is over. 

Pregnancy is an indication for weaning. It is impossible for a 
woman to nourish three individuals, herself, a baby on the breast 
and another in utero. Someone is sure to suffer, most often the 
baby on the breast. ^ , 

Acute disease in the mother is often an indication for weaning. 
If the disease is contagious, it is usually advisable to wean the 
baby to protect it from contagion. The younger the baby, the 
less likely it is, however, to contract the disease, because babies are 
born with a natural immunity to many of the contagious diseases. 
If it is not contagious, the question of nursing must be decided on 
the circumstances in the individual case. If the disease is a mild 



138 DISEASES OF NUTRITION 

one, the baby may be kept on the breast or taken off temporarily 
while the secretion of the breast is kept up in other ways. If the 
disease is a severe one, the milk will probably dry up wholly or in 
part and become poor in quality, so that the baby will have to be 
taken off the breast anyway, even if the condition of the mother 
warranted the continuance of the nursing, which it usually does not. 

The development of a chronic disease in the mother is usually an 
indication for weaning. In other instances, although the baby is 
thriving, the strain of nursing enfeebles and debilitates the mother. 
The decision as to weaning in such cases must be made on the 
merits of the individual case, bearing in mind the fact that it is a 
mother's duty to nurse her baby as long as she can do it without 
serious detriment to herself. The older a baby is, the less depend- 
ent it is upon breast-milk. Weaning is justifiable, therefore, for 
slighter disturbances of the mother's health after the first few 
months than it would be before. 

It is, unfortunately, not often necessary to decide when to wean, 
because the milk gives out and the baby has to be fed artificially. 
Under these circumstances the milk usually diminishes slowly and 
the baby is gradually weaned without difficulty. 

If the supply of milk continues sufficient in amount, it is ad- 
visable to wean the baby when it is between ten and twelve months 
old. Babies rarely thrive on the breast alone more than a year, and 
seldom as long as this. They become anemic and, while fat, 
usually get flabby. The cause of the anemia is that breast-milk 
does not contain sufficient iron to cover the need for this substance 
and the iron stored in the liver at birth is usually used up before 
this time. If a baby is doing fairly well on the breast, it is in most 
instances advisable to continue nursing through the summer 
months, even if the baby is a year or more old in the autumn, be- 
cause babies on the breast are much less liable to disturbances and 
infections of the digestive tract than those that are artificially fed. 
A baby should never be weaned in the spring to avoid weaning in 
the summer. The old idea that it is very dangerous to wean babies 
in the summer originated in the fact that babies weaned in the 
summer got contaminated milk and were therefore made sick, 
while those weaned in the spring got uncontaminated milk and 
were therefore less often upset. The truth of the matter is that the 
older a baby is, the better able it is to take an artificial food, pro- 
vided that food is suitable and clean. 

Babies should always be weaned slowly, if possible. It is much 
easier for the mother and the baby is much less likely to be made 
ill by the change to artificial food. If it is made ill, it can usually 



AND INFANT FEEDING 139 

be put back on the breast again without difficulty. If it is weaned 
suddenly and the milk is gone, as it usually is in a few days, the 
baby cannot get anything from the breast at first, although it may 
later. It is often possible to bring back the milk, by putting the 
baby to the breast regularly, even several weeks after breast feeding 
has been omitted. Weaning is much easier if the baby has been in 
the habit of taking one bottle a day from the beginning of nursing. 
This custom is advantageous for many reasons. It gives the 
mother far more freedom, enables her to nurse longer, gets the 
baby accustomed to taking the bottle as well as the breast and 
habituates it to the digestion of an artificial food, as well as showing 
what sort of artificial food it can take. If the baby has had one or 
more bottle feedings daily, there is usually no trouble in weaning it 
gradually and neither mother nor child is disturbed. If it is more 
than a few months old and not accustomed to the bottle, it is 
much harder to wean it gradually, because the baby will refuse all 
food except the breast-milk and cannot be starved into taking it. 
When the baby will not take food in any way except from the 
breast, and when it has to be weaned because of the mother's 
illness or for some other emergency, the breast feeding has to be 
stopped suddenly. It is best to separate the baby from its mother, 
but in any case some other person must give it its food. It cannot 
be expected to take it from its mother, whom it has been in the 
habit of nursing. A little baby should be given the bottle. An 
older baby should be fed from a glass or with a spoon. If it refuses 
to take food after reasonable coaxing and urging, it should be 
allowed to go hungry until the next feeding. Most babies will 
yield to the pangs of hunger after from twenty-four to forty-eight 
hours and take what is offered to them. Occasionally, however, a 
baby will not give in and it has to be forced to take food or fed with 
a tube to save it from starvation. Such babies should always be 
closely supervised because of the possibility of the development of 
acidosis. 

When a baby has been taking one feeding of artificial food a day, 
there is no difficulty in deciding what food to give it. The same 
food is continued, the number of feedings being merely increased. 
When a baby that has been exclusively breast-fed can be weaned 
slowly, it is safe to give it a fairly strong food. It is usually possible 
when it is nine months or more old, to wean it directly on to a 
dilution of whole milk. It is also usually advisable to add starch to 
the mixture, because a baby of this age is perfectly capable of 
digesting starch and because, outside of milk, starchy foods will 
form the principal part of its diet for the next few months. A 



140 DISEASES OF NUTRITION 

mixture of three parts of whole milk and one part of a 3% barley- 
water, giving fat 3%, sugar 3.36%, proteins 2.62% and starch 
0.75%, is a reasonable one for a baby of this age. When a baby is 
weaned suddenly, it should always be given a weaker mixture than 
a baby of the given age would naturally take, in order to avoid, if 
possible, disturbance of the digestion from the artificial food. It is 
easy to strengthen the food if it agrees, difficult to correct dis- 
turbances of the digestion caused by too strong a food. The 
strength of the mixture must depend, largely, of course, on the 
age of the baby. Whey mixtures are the most suitable for young 
babies, mixtures with cereal diluents for older babies. 






AND INFANT FEEDING 141 



CHAPTER XII 
WET-NURSES 

There can be no question that the most suitable food for an 
infant that is so unfortunate as not to be nursed by its mother is 
the milk of another woman. In fact, the milk of some other woman 
is not infrequently better for a baby than that of its own mother, 
when she is nervous and feeble while the stranger is placid and 
strong. In former days so little was known about the artificial 
feeding of infants that unless a wet-nurse was obtained the pros- 
pects of survival of a baby deprived of its mother's milk were not 
over-bright. At present, however, on account of the great ad- 
vances which have been made in artificial feeding, a normal baby 
can be expected to do well, if artificially fed, provided that its 
feeding is directed by someone familiar with the subject. Wet- 
nurses are not, therefore, the necessity for well babies which they 
were in the past. The situation is different, however, in the case of 
premature, feeble and ill babies. Many of these can be saved by 
human milk who, without it, would surely die. Many others, who 
eventually pull through on artificial feeding after months of illness, 
can be immediately restored to health by human milk. A very 
good rule to follow is not only never to allow a baby to die, but 
never to allow a baby to get into a condition in which it may die of 
disturbances of nutrition or of diseases of the digestive tract with- 
out getting it a wet-nurse, provided a wet-nurse can be procured. 

Wet-nurses are often not an unmixed blessing in a family. They 
realize their own importance and not infrequently take advantage 
of it, causing much disturbance in the household. In general, 
however, they are much like other people, good, bad and indiffer- 
ent. Like other people, too, how they conduct themselves depends 
very largely on how they are treated. Even if they do cause 
trouble, however, a family should be willing to put up with con- 
siderable domestic disquiet for the sake of saving their baby's 
life. Household worries are not to be compared with the anxiety 
attendant on the illness of a baby. 

Every mother dislikes to have another woman nurse her baby. 
She should, however, in the first place, appreciate the fact that if 
she was fulfilling her duty to her baby, a wet-nurse would not be 
necessary, and in the second place, should be not only willing, but 



142 DISEASES OF NUTRITION 

glad, to sacrifice her own feelings for the good of her infant. There 
is, of course, no possibility of the transference of mental, moral or 
physical characteristics from the nurse to the baby. If there was, 
it would be far better for many babies to have wet-nurses than to 
nurse their own mothers. It makes no difference to the baby what 
is the color, race, creed, disposition or moral character of the nurse, 
provided her milk is of good quality and sufficient in quantity. 

It is sometimes said that it is wrong to employ wet-nurses, 
because it is immoral to deprive one baby of its natural nourish- 
ment and give it to another. This objection is not well-founded, 
because women do not go out as wet-nurses for pleasure, but 
because they are compelled to support themselves and their babies. 
The wages which they earn as wet-nurses are higher than they can 
get in any other way and, if they board their babies out, they are 
enabled to board them in better places and to save money for the 
future. It is always advisable, however, for a nurse to have her 
own baby with her. Her baby can then be properly cared for, she 
becomes fond of it and is more likely to care for it in the future, 
and, if she has made a mistake, is more likely to live straight in the 
future for the sake of her baby. It is often an advantage to the 
foster baby for the nurse to have her own baby with her, because 
she is happier and more contented. In many instances, moreover, 
the foster baby is, at any rate at first, not strong enough to empty 
the breasts and to keep up the supply of milk. Under these cir- 
cumstances, the nurse's baby can empty the breasts and keep them 
going. Many women are able, moreover, to nurse both babies. 

Wet-nurses are often objected to on the ground of expense. This 
must vary, of course, with the locality and the circumstances in the 
individual case. It is safe to say, however, that the cost of the 
wet-nurse, including her board and that of her baby, will be less 
than that of an artificial food and the doctor's bills, which will be 
saved. 

Qualifications of a Wet-Nurse. — A wet-nurse should be healthy 
and free from syphilis, tuberculosis and other chronic diseases. 
No woman should be accepted as a wet-nurse without a complete 
physical examination by a competent physician. Syphilis cannot 
be positively excluded, even if neither mother nor child show any 
evidences of it. A Wasserman test should be done, therefore, if it is 
practicable. Equal care should be taken to determine, however, 
that the baby that she is to nurse is not syphilitic. It is just as bad 
to have the baby infect the wet-nurse with syphilis as it is to have 
the wet-nurse infect the baby. It is impossible to determine from 
the general appearance of a woman or from the size, shape or feel- 



AND INFANT FEEDING 143 

ing of her breasts whether she has or has not a good supply of milk. 
Many small, thin women have much milk, and many large, 
vigorous-looking women but little milk. Small breasts often 
secrete much milk, and large breasts but little milk. The milk is 
secreted by gland tissue, not by fat, and it is impossible to tell by 
the appearance or feeling of a breast what is fat and what is gland 
tissue. The ease with which milk can be expressed from the breast 
is also unreliable as a guide, because a baby can often obtain much 
milk from a breast from which but little milk can be expressed, 
while in other instances where there is but little milk, it can all be 
easily expressed. The only way in which the quantity of milk 
which the breast is secreting can be positively determined is by 
weighing the wet-nurse's own baby before and after each nursing 
for at least twenty-four hours. Next to this is the appearance of 
her baby. If it is thriving, it is evident that it gets a sufficient 
supply of milk and that this milk is of good quality. It is useless to 
examine the milk to determine whether it will be suitable for an- 
other baby or not, partly because of the variation in the milk from 
day to day and nursing to nursing, and partly because it is im- 
possible to know in advance whether or not a given milk will agree 
with a given baby. 

The composition of breast-milk being the same from the end of 
the colostrum stage until nearly the end of lactation, it is not 
necessary that the foster baby and the nurse's baby shall be of the 
same age. It is not advisable, however, if prolonged nursing is 
anticipated, to take a woman as a wet-nurse who is approaching the 
end of the period of lactation. The only objection, however, is 
that her milk is likely to give out and that it will be necessary to 
procure another nurse. It must be remembered that if a feeble or a 
young baby is put to the breast of a woman with an abundance of 
milk, it cannot empty the breast and that, the stimulation to 
secretion being removed, the supply of milk will diminish and 
perhaps cease. Many a good nurse has been spoiled in this way 
and discharged as having no milk when the trouble was not with 
her but with the baby. It is of great advantage under these 
conditions for the nurse to have her own baby with her to empty 
the breasts. A small or young baby may be upset, also, by taking 
too much food from a full breast which has been nursed by an 
older child. This mishap can be prevented by weighing the baby 
before and after nursing. 

Management of Wet-Nurses. — A wet nurse should be given 
the sort of food to which she is accustomed, and should be given the 
sort of work to do which she has been in the habit of doing. If a 



144 DISEASES OF NUTRITION AND INFANT FEEDING 

woman that has been in the habit of doing hard, manual labor and 
eating plain, coarse food is given rich food and allowed to sit about, 
she is likely to become ill and the equilibrium of her milk is almost 
certain to be disturbed. On the other hand, a woman that has 
been in the habit of leading a sedentary life, as a seamstress, for 
example, and eating delicate food, cannot do hard work and eat 
coarse food without some disturbance of her milk resulting. Many 
a good wet-nurse has been spoiled by lack of attention to these 
details. 

Methods of Procuring Wet-Nurses. — It is almost always pos- 
sible to find a wet-nurse if the quest is undertaken with sufficient 
energy. They are most readily obtained at maternity homes and 
hospitals. In other instances they may be obtained through 
physicians and district nurses, or by advertising for them. There 
has been in Boston, for several years, a Directory for Wet-Nurses, 
where a considerable proportion of the women who wish to be 
nurses go. They are examined physically and the Wasserman test 
is done on them. The quantity and quality of their milk are also 
determined. They are not sent out unless they are healthy and 
their milk satisfactory. When they are through with one case they 
return to the Directory and wait for another. A reasonable fee is 
charged by the Directory for providing them. 1 This is the best 
solution of the problem in that it makes it easy to find a wet-nurse, 
assures the health of the wet-nurse, and is available for people liv- 
ing not only in the vicinity but also at a distance. 

In many instances in which it is impossible for some reason to 
get a wet-nurse, breast-milk can be expressed from the breasts of 
one or several women and fed to the baby in a bottle. It makes no 
difference in the result whether the baby gets it directly from the 
breast or indirectly from the bottle. It is breast-milk just the 
same. The Boston Floating Hospital has, for several seasons, 
obtained considerable amounts of breast-milk in this way through 
the cooperation of several of the philanthropic and nurses' soci- 
eties in Boston, and used it with good result. 2 

Breast-milk may also be preserved by freezing and used when 
desired. Schlossmann always has a number of wet-nurses at his 
hospital and during the winter months, when he does not use so 
much breast-milk as at other times, he saves the excess and 
freezes it, holding it in a refrigerator until the summer months, at 
which time the demand is greater. He then takes it as needed and 
claims very good results with it. 

1 Talbot: Journal A. M. A., 1911, vol. lvi, p. 1715. 

2 Talbot: Boston Medical and Surgical Journal, 1911, clxiv, 290. 



SECTION III 
ARTIFICIAL FEEDING 



CHAPTER XIII 
COW'S MILK. CHEMISTRY AND BIOLOGY 

COLOSTRUM 

The colostrum of cow's milk is never used in infant feeding, 
except by accident, and, for that reason, will only be treated in 
brief. It is probable that the explanation of the presence of the 
colostrum bodies in cow's milk is the same as in human milk. 

Colostrum is a thick, shiny, yellowish or reddish fluid with a 
taste more salty than that of normal milk. 1 It is sometimes alka- 
line, but more often acid. The specific gravity ranges between 
1.046 and 1.080, and it is richer in solids than ordinary milk. The 
appearance and composition gradually change during the course of 
a week, at the end of which time it becomes milk suitable for use. 

The following analysis given by Engling 2 shows the way in which 
the milk changes: 

TABLE 29 







Number of hours after calving 


Normal 
Milk 




Imme- 
diately 


10 


24 


48 


72 




Water 


73.17 


78.77 


80.63 


85.81 


86.64 


87.75 


Casein 


2.65 


4.28 


4.50 


3.25 


3.33 


3.00 


Albumin 
Globulin . . 


16.56 


9.32 


6.25 


2.31 


1.03 


0.50 


Extractives . 


3.54 


4.66 


4.75 


4.21 


4.08 


3.40 


Sugar 


3.00 


1.42 


2.85 


3.46 


4.10 


4.60 


Ash 


1.18 


1.55 


1.02 


0.96 


0.82 


0.75 



1 Jensen's Milk Hygiene (Pearson) : Phil, and London, 1907, p. 12. 

2 Taken from Jensen's Milk Hygiene (Pearson), Phil, and London, 1907, 



p. 30. 



145 



146 DISEASES OF NUTRITION 

The fat in colostrum has a somewhat higher melting point and is 
poorer in volatile fatty acids than the fat in ordinary milk. 1 

The proteins in the colostrum of cows resemble those in human 
milk in that the greater part of them will coagulate. 



Appearance, Smell, Taste. — When milk is perfectly fresh, it is 
a white, or yellowish white, opaque fluid. It separates into two 
distinct layers, when it is allowed to stand undisturbed for some 
time. The upper and lighter layer, which consists largely of 
globules of fat and is called "cream," is yellower than the lower 
layer, which is white or bluish white and is known as "skimmed 
milk." When it is pure and fresh, milk has either a faint, insipid 
odor, or no odor at all, and a mild, faintly sweetish taste. 

Microscopic Appearance. — Like human milk, it contains many 
minute fat droplets suspended in the form of an emulsion. 
There are more ultramicroscopic particles than in human milk, 
because it contains a larger amount of casein. 

Specific Gravity. — The specific gravity of the fat in cow's 
milk is different in different breeds of cattle and varies between 
0.922 and 0.937. 3 The specific gravity of whole milk varies 
between 1.028 and 1.035 at 15° C. (60. F°). Jenson gives 1.027 to 
1.040). 

Reaction. — The reaction depends either on the carbon dioxid 
and acid phosphates 4 or on the mono- and diphosphates in the 
milk. 5 Cow's milk is described as amphoteric to litmus paper. On 
standing exposed to the air, it becomes acid. The degree of the 
acidity and the rapidity of the change depend on the kind and on 
the amount of bacterial activity by which milk sugar is split up 
into lactic acid. Fresh milk has been studied with different in- 
dicators and it has been found that 100 c. c. of milk has the same 
alkaline reaction toward blue litmus as 41 c. c. of N/10 caustic 
soda, and the same acid reaction toward phenolphthalein as 

1 Nilson: Maly's Jahrsber. 21. 

2 The following publications are drawn from freely in the ensuing section : 
Kastle and Roberts: The Chemistry of Milk Hygiene, Lab. Bulletin No. 56, 
Washington, 1909, p. 315; Jensen's Milk Hygiene, Phila. and London, 1907, and 
Voltz: Chemie der Kuhmilch in Oppenheimer Handbuch der Biochemie des 
Menschen und der Thiere, vol. iii, first half, Jena, 1910, 386; Hammarsten 
A Textbook of Phys. Chemistry, N. Y., 1912; Koeppe and Raudnitz in Som- 
merfeld's Handbuch der Milchkunde, Wiesbaden, 1909. 

3 Heischmann : Lehrbuch der Milchvirtschaft., Heinsiws Machf., Bremen. 

4 Leach: Food Inspection and Analyses, N. Y., 1907, ii. 
6 Richmond: Analyst, 1900, xxv, 121. 



AND INFANT FEEDING 147 

19.5 c. c. of N/10 sulphuric acid. 1 Cow's milk conducts electric 
currents because it contains dissolved salts. Fifty-eight per cent of 
the molecules of the mineral salts in cow's milk and 26% in human 
milk are dissociated. 2 

Quantity. — Since the quantity of milk is of moment only to the 
milk producer, it will not be considered here. 

The Coagulation of Cow's Milk. — By the coagulation of cow's 
milk is meant all the processes concerned in the precipitation 
of casein. 

(a) Effect of Acids on Coagulation of Milk. — Perfectly fresh 
amphoteric milk does not coagulate on boiling. A pellicle, con- 
sisting of coagulated casein and lime salts, is formed on the surface. 
This reforms rapidly after being removed. 3 Fresh milk does not 
coagulate on boiling, even after a current of carbon dioxid has 
been passed through it. As milk ages, lactic acid begins to form 
and a stage is reached in which milk, which has previously had 
carbon dioxid passed through it, coagulates on boiling. At a 
second stage it coagulates on heating without the treatment with 
carbon dioxid. When the lactic acid is present in sufficient 
amount, the milk coagulates spontaneously at room temperature, 
forming a solid mass. The amount of lactic acid formed in milk 
depends both upon the amount of sugar in the milk and the type of 
organism. The acidity may vary between 0.3% and 1.3%. In 
most instances, when a vigorous strain of organism is used, the 
amount of lactic acid varies between 0.5% and 0.6%. 4 

Kastle 5 studied the coagulation of sour milk in Washington. 
His results are given in table 30 on page 148. 

The milk which coagulated spontaneously at 65° C. (145° F.) had 
an acidity of 0.711. As a general rule, the milks which are most 
easily coagulated by heat have the highest acidity. On the other 
hand, samples of milk with an acidity of 0.54% of lactic acid, which 
did not coagulate on boiling, have been reported. 6 Fresh milk, 
according to Richmond, 7 has an acidity of 20 degrees, correspond- 
ing to 0.18% lactic acid. He found that milk curdled on boiling 
when it had an acidity of 33 degrees, corresponding to 0.29% of 
lactic acid. 

1 Courant: Uber die Reaction der Kuh und Frauenmilch. Inaug. Diss., 
Breslau, 1891, 9. 

2 Koppe: Jahrb. f. Kinderh., 1898, xlvii, 389. 

3 Hammarsten: loc. cit. 

4 Leischmann: Bact. acidi lactici. 
6 Kastle and Roberts: loc. cit. 

6 Stokes: Analyst: xvi, 22. 

* Richmond: Analyst, 1900, xxv, 121. 



148 



DISEASES OF NUTRITION 



TABLE 30 



The Relation of the Acidity and the Temperature op Milk to Coagu- 
lation (Kastle) 



Acidity 


Temp. 


Time of heating 


Curdled = + 


per cent. 


°C. 


minutes 


Not curdled = — 


0.711 


65 





+ immediately 


.594 


65 


1 


+ 


.576 


65 


2 


+ 


.567 


65 


1 


+ 


.554 


60 


2 


+ 


.531 


65-67 


2 


+ 


.513 


65 


2 


+ 


.478 


60 


5 


+ 


.450 


65 


1V2 


+ 


.441 


66 


1 


+ 


.387 


65 


5 


+ 


.351 


65-67 


2 


+ 


.342 


78.5 


2 


+ 


.342 


66 


5 


— 


.315 


70 


10 


+ 


.315 


70 


5 


+ 


.306 


75 


3 


— 


.306 


65 


5 


— 


.288 


70 


5 


— 


.261 


65-74 


5 


— 


.252 


100 


1 


— 


.252 


70 


5 


— 


.243 


100 


1 


— 


.243 


72-74 


10 


— 


.243 


65 


10 


— 


.234 


65 


5 


+ 


.225 


65-67 


2 




.198 


65 


5 


— 


.180 


65 


5 


— 















(b) Precipitation with A cids. — Casein may be precipitated from 
cow's milk by dilute acids. It requires 50 to 70 c. c. of N/10 hy- 
drochloric acid, or 60 to 80 c. c. of N/10 acetic acid to give the best 
results. When casein is treated with dilute acids, two chemical 
reactions take place; first the acid combines with the calcium in the 
casein, forming a base-free casein or a casein set free from its 
combination with calcium ; on the addition of more acid, the casein 
molecule combines directly with the acid, forming a salt of the 
acid. This action is hastened by an increase of temperature. 
(Van Slyke). 

It is supposed by Van Slyke to be an absorption of acid by the 



AND INFANT FEEDING 149 

casein while Robertson believes that the acid goes in combination 
with the casein. Since such an excess of acid is not found in the 
physiology of the infant, casein may be considered as having the 
properties of an acid in subsequent discussions. 

An excess of acid will redissolve the precipitate. 1 

(c) Rennin Coagulation. 2 ' 3 — The following are some of the more 
important facts in reference to the action of rennin upon milk 
casein in causing coagulation: 

(I) The presence of soluble lime salts appears to be necessary 
for the coagulation of milk by rennin. 

(II) The reaction must be neutral to litmus, or acid, but not 
alkaline. Acids, whether organic or inorganic, although they differ 
from one another in respect to the intensity of the influence which 
they exert on the action of rennin, all have a very marked effect 
upon the coagulation of calcium casein by rennin. The usual 
explanation of this effect of acids upon the action of rennin is that 
the acid which is added dissolves the insoluble calcium phosphate 
of milk and thus increases the amount of soluble calcium salts. 
The claim is also made by some that the acid has in itself some 
direct influence upon the action of rennin. 

(III) The dilution of milk with water delays the coagulation 
of milk by rennin, because the proportion of soluble calcium salts is 
decreased. The addition of calcium chlorid or of a free acid to milk 
diluted with water not only hastens the time of coagulation, but 
also increases the amount of calcium coagulated. 

(IV) Different chemical compounds affect the coagulation of 
milk by rennin in different ways. 

(V) The addition of foreign, inert matter, like starch or saw- 
dust, hastens rennin action. 

(VI) The temperature affects the rapidity of coagulation of 
milk by rennin. For complete action, the time decreases as the 
temperature increases. In a given time, rennin coagulates milk 
most completely at from 106° to 108° F., and less completely at 
temperatures above and below this point. 

(VII) The temperature at which coagulation takes place affects 
the character of the coagulum. At 60° F. the curd is flocculent, 
spongy and soft; at from 77° to 113° F. it is more or less firm and 
solid; at 122° F. and above it is very soft, loose and more or less 
gelatinous. 

1 Schlossmann and St. Engel in Konig: Der mensch. Nahrungs, u. Genus- 
mittel II, Berlin, 1914, 598. 

2 Van Slyke: Arch. Pediatrics, 1905, xxii, 515. 

3 Bosworth: Jour. Biol. Chem., 1913, xv, 231. 



150 DISEASES OF NUTRITION 

(VIII) Rennin heated for some time to over 140° F. becomes 
permanently weaker or inactive. It is somewhat affected at about 
120° F. Weak solutions are more easily affected by an increase of 
temperature than are strong solutions. 

(IX) An increase in the amount of rennin in proportion to the 
milk hastens the rapidity of coagulation as does also an increase in 
the strength of the rennin. 

(X) Freshly drawn milk curdles more completely than it does 
after it is allowed to cool. This is because it is warmer and per- 
haps because of the presence of carbon dioxid. 

(XI) Milk heated above 160° F. for a considerable length of 
time coagulates less rapidly than unheated milk. The coagulum of 
heated milk is highly flocculent, unless soluble calcium salts or 
some acid are added to it. Boiled milk is not coagulated normally, 
if at all, by rennin. 

Hammarsten was the first to show that the coagulation of milk 
by rennin was due to a soluble ferment which acted directly on the 
casein, producing, as he thought, two substances, the insoluble 
curd (Kase or paracasein), and a soluble product whey-protein 
(Molkeneiweiss). He also showed that the change of casein to 
paracasein was independent of coagulation, the coagulation being 
due to the presence of soluble calcium salts. 

A great number of papers have been published upon this subject 
since the early work of Hammarsten. As his explanation of the 
action of rennin has been generally accepted as correct, most of the 
recent investigations have been concerned with the influence of 
the soluble salts upon the coagulation. These investigations have 
shown that the soluble salts of calcium, barium and strontium 
favor or hasten coagulation, while the salts of ammonium, sodium 
and potassium retard or inhibit coagulation. 

Recently, Van Slyke and Bosworth l have shown that casein 
and paracasein are acids having the same percentage composition; 
that the molecular weight of casein is probably 8,888, while the 
molecular weight of paracasein is one-half that of casein, 4,444; 
that the combinations of casein with barium or strontium are 
insoluble in water while the combinations with one equivalent of 
ammonia, sodium, or potassium are soluble; and that ammonium, 
sodium or potassium casemates can be changed by rennin to 
paracaseinates which are soluble and are precipitated by calcium 
chlorid as calcium paracaseinates. 

These facts seem to indicate three things: 

First, that the action of rennin is the hydrolytic splitting of the 
1 Van Slyke and Bosworth: Jour. Biol. Chem., 1913, xiv, 203-236. 



AND INFANT FEEDING 151 

casein molecule into two similar molecules of paracasein; perhaps 
in somewhat the same manner as maltose is split into two molecules 
of dextrose. 

Second, that it would seem doubtful if Hammarsten's whey- 
protein could be one of the products of rennin action. 

Third, that rennin is not, strictly speaking, a coagulating fer- 
ment, the coagulation of paracasein being due to the fact that the 
calcium paracaseinates are less soluble than the calcium casemates, 
especially in the presence of the soluble salts of calcium, barium and 
strontium. The coagulation is, therefore, a secondary effect, the 
result of a change in solubilities. 

The curd formed in the coagulation of milk contains large 
quantities of calcium phosphate. Courant 1 believes that calcium 
caseinate on coagulation may carry down with it, if the solution 
contains dicalcium phosphate, a part of this as tricalcium phos- 
phate, leaving monocalcium phosphate in the solution. 

When the phenomena of coagulation of milk are watched under 
the ultra-microscope 2 the small particles of casein are seen to 
clump together before there is any visible gross coagulation. As 
more and more particles clump together they become visible. The 
milk of fresh cows is better suited to rennin coagulation than the 
milk of cows that are nearly dry. 

(d) The Effect of the Addition of Alkalies on the Curdling of 
Milk. — It is necessary to bear in mind the following facts, when 
considering the action of alkalies on casein. Bosworth and Van 
Slyke 3 have shown in a pretty series of experiments that " casein is 
a protein showing the characteristic property of an acid, in that it 
combines with metals or bases to form compounds known as 
casemates." For example, the compound of casein containing 
the largest amount of a monovolent metal-like sodium could be 
represented by the formula Na 8 casein (sodium caseinate); the 
corresponding calcium compound is Ca4 casein (calcium caseinate). 
It has not been definitely settled yet which particular compound of 
calcium is present in milk, but it is probably either tetra-calcium or 
tri-calcium caseinate. When the calcium caseinate of milk is 
acted on by rennin, it is changed into another compound called 
calcium paracaseinate. As the result of this action one molecule of 
calcium caseinate is split into two molecules of calcium paracase- 
inate. This reaction may be represented in the following formula: 
Ca4 caseinate = Ca2 paracaseinate + Ca2 paracaseinate. Para- 

1 Courant: loc. cit. 

2 Kreidl and Neumann : Pfluger's Arch, 1908, 123, 523. 

3 Bosworth and Van Slyke: Am. Jour. Dis. Child., 1914, vii, 298. 



152 



DISEASES OF NUTRITION 



casein, like casein, possesses acid properties, but it only has one-half 
the combining power of casein. Calcium paracaseinate is less 
soluble than the corresponding calcium caseinate present in the 
milk from which it is formed, and, therefore, when milk curdles, 
it is precipitated as a solid. If reninn is added to a solution of 
sodium caseinate the caseinate is split into two molecules of sodium 
paracaseinate, but no precipitation or curdling takes place. This 
is explained by the fact that sodium caseinate is very soluble. If a 
small amount of a soluble calcium salt (calcium chlorid) is added 
to the solution of sodium paracaseinate, curdling occurs at once, 
the curd being calcium paracaseinate. This chemical reaction 
may be illustrated in the following manner: 

Sodium paracaseinate (soluble) + calcium chlorid = calcium 
paracaseinate (insoluble) + sodium chlorid. The following table 
(Bosworth and Van Slyke) illustrates the effect of increasing 
amounts of sodium citrate on the coagulation of milk: 

TABLE 31 
Effect of Sodium Citrate on the Curdling of Milk by Rennin 



Grains of sod. citrate 


Amt. rennet solution 


Minutes required for 


to 1 oz. of milk 


used per 100 c. c. 


milk to curdle 


0.0 


2. 


6 


0.20 


2. 


7V 2 


0.40 


2. 


sy 2 


0.65 


2. 


ii 


0.85 


2. 


31 


1.00 


2. 


37 


1.25 


2. 


47 


1.50 


2. 


62 


1.70 


2. 


not curdled 


1.90 


2. 


not curdled 


2.10 


2. 


not curdled 



The addition of increasing amounts of sodium citrate to milk 
lengthens the coagulation time of the milk up to the point when 1.7 
grains per ounce is added, after which the milk does not coagulate. 
In actual practice the addition of this amount prevents the forma- 
tion of a curd in the infant's stomach. The explanation of this 
fact is that the sodium replaces some of the calcium in the caseinate 
and forms sodium caseinate of calcium-sodium caseinate. When 
rennin is added this double salt is changed to calcium sodium 
paracaseinate, which, owing to the presence of sodium, is not 
curdled. 



AND INFANT FEEDING 



153 



Lime Water. — "When lime water is added to cow's milk un- 
til it is neutral or faintly alkaline to phenolphthalein, a basic 
calcium casein is formed which is not acted upon by rennet and 
will not form a curd even in the presence of lime salts." * This may 
be explained by the fact that casein is not coagulated by rennin 
when the solution is alkaline. In actual practice the addition of 
lime water to milk may increase its alkalinity to such a point that 
the stomach will not secrete the requisite amount of acid to make 
the stomach contents neutral or acid. A neutral or acid reaction is 
necessary for the coagulation of milk by rennin. 

Anti-rennin may be formed by injecting rennin into horses until 
a ferment is formed which destroys the action of rennin. 2 ' 3 When 
it is added to milk with rennin it prevents the coagulation of 
milk. 

The Chemical Composition of Cow's Milk. — The individual 
food components, fats, lactose, proteins and salts will be con- 
sidered separately and then as a whole. The variations in the 
composition of the milk of a single cow is only of slight interest in 
this connection, because the milk used in infant feeding is in 
almost all instances mixed milk. 

Nitrogenous Bodies. — The following table, compiled by Leach, 4 
gives a good idea of the average amounts of the various food 
components and also of the extreme variations in their per- 
centages : 

TABLE 32 



Cow's milk 


Specific 
gravity 


Water 


Casein 


Albu- 
min 


Total 
protein 


Fat 


Lac- 
tose 


Ash 


Minimum 

Maximum 

Average 


1.026 
1.037 
1.031 


80.32 
90.32 

87.27 


1.79 

6.29 
3.02 


0.25 
1.44 
0.53 


2.07 
6.40 
3.20 


1.67 
6.47 
3.64 


2.11 
6.12 

4.88 


0.35 
1.21 
0.71 



Table 33 shows how much the composition of the morn- 
ing and evening milk may vary. These figures are the aver- 
age from 29,707 tests of milk made by Droop Richmond in 
England. 



1 Van Slyke: Archives of Pediatrics, xxii, 515. 

2 Hammarsten: loc. cit. 

3 Morgenroth: Centr. Bakt., 1900, xxvi, 349; Fuld and Spiro: Zeitschr. phys. 
Chem., 1900, xxxi, 132. 

4 Leach: Food Inspection and Analysis, New York, 1907. Table compiled 
from Koenig's Chemie der Menschlechen Nahrungs und Genussmittel. 



154 



DISEASES OF NUTRITION 

TABLE 33 



Milking 


Fat 
per cent. 


Lactose 
per cent. 


Protein 
per cent. 


Ash 
per cent. 


Solids 
per cent. 


Morning 

Evening 


3.44 
3.90 


4.71 
4.69 


3.43 
3.39 


0.74 
0.73 


12.34 
12.71 



Cows of different breeds give milk of somewhat different com- 
position and, although it was supposed that cattle from mountain 
regions gave a richer milk than those from the lowlands, there are 
many exceptions to this statement. 1 The Jersey and Guernsey 
breeds give a rich milk and the Holstein and Ayrshire cattle are apt 
to give a milk poorer in fat but this is more suitable for infant 
feeding. The fat globules in the Jersey milk are almost three times 
that of the Holstein. The milk of different individuals of the same 
herd and species vary in composition and it is fair to assume that 
the production of rich milk is distinctly an " individual property 
that is due to the physiological peculiarities of the gland cells of the 
animal, and which to a great degree is hereditary." (Jensen.) 

Nitrogenous Compounds. — The total nitrogenous compounds 
are given by Van Slyke as 3.2% and by Babcock as 3.8%. The 
principal proteins are casein and albumin, or insoluble and soluble 
proteins. The principal soluble proteins are lactalbumin and 
lactoglobulin. There are probably other substances also, but little 
is known about them. The figures as to the relation of the casein 
to the soluble nitrogenous bodies in the milk vary greatly, being all 
the way from 2.6:1 2 to 8:1. 3 The average according to Van Slyke 
is 3.6 parts of casein to one part of soluble protein. (In human 
milk the relation is approximately 1:1.) Table 32 shows that the 
amount of casein and albumin in cow's milk may vary materially. 

Casein. — Cow casein is a white powder, with a specific gravity of 
1.259. It causes moist blue litmus paper to turn red and shows the 
characteristic properties of an acid, in that it combines with metals 
or bases to form compounds known as casemates. 4 One gram 
of ash-free casein develops 5.742 calories according to Schloss- 
mann; 5 5.85 according to Sherman. 6 The molecular weight of 

1 See Jensen's Milk Hygiene, Phila. and London, 1907. 

2 Van Slyke: Archives of Pediatrics, 1905, xxii, 509. 

3 Stohmann: Milch und Molkereiproducte 1898, 58, quoted by Czerny and 
Keller; Hammarsten: Jahresber. f. Thierchemie, 1896, xxv, 206; Schloss- 
mann: Verh. d. 13 Vers. d. Gesellsch. f. Kinderh. in Frankfurt, 1896, 78. 

4 Bosworth and Van Slyke: Am. Jour. Dis. Children, 1914, vii, 298. 

5 Schlossmann: quoted by Raudnitz in Sommerf eld's Handbuch. 

6 Sherman: Chemistry of Food and Nutrition, N. Y., 1911, 123. 






AND INFANT FEEDING 155 

casein is 8888. 1 It has the following composition: C. 53.0; H. 7; 
N. 15.7; S. 0.8; P. 0.85; O. 22.65%. 2 

The question whether the casein from different kinds of milk is 
identical or whether there are several caseins cannot be decided by 
the elementary composition. 2 It is probable that chemically they 
are much the same, but that biologically they are different. (See 
Human Casein.) 

Casein dissolves readily in water with the aid of alkali or alkaline 
earths, also calcium carbonate from which it expels carbon dioxid. 
Such solutions are precipitated by dilute acids and redissolved by 
stronger acids (s. 5-2.8 grams HCL to 10.0 grains casein). It is 
insoluble in alcohol and water. 

The casein in milk is in combination with calcium in the form of 
calcium caseinate. It has not been definitely settled as yet which 
particular compound is in milk, but it is probably either tetra- 
calcium or tri-calcium caseinate. 3 

Osborne and Quest 4 have shown by hydrolysis that casein 
contains glycocoll 0%, alanine 1.5%, valine 7.2%, leucine 9.35%, 
protein 6.7%, phenylalanine 3.2%, glutanine acid 15.55%, aspartic 
acid 1.39%, cystine series 0.5%, tyrosine 4.5%, oxyproline 0.23%, 
histidein 2.50%, arginine 3.81%, lysine 5.95%, tryptophan 1.5%, 
diaminotrioxy-dodecanic acid 0.75%, NH 3 1.61%, S. 0.76%, 
P. 0.85%. The figures quoted by Raudnitz 5 vary somewhat 
from these. 

Paracasein. — Paracasein is a body closely related to casein. 
When paracasein is in combination with a salt the compound is 
known as the paracaseinate of that salt. For instance the combina- 
tion with calcium is known as calcium paracaseinate. It has been 
shown above that calcium paracaseinate is insoluble, while sodium, 
potassium and ammonium paracaseinate are soluble. Calcium 
paracaseinate is similar to calcium caseinate, but it cannot be 
recoagulated by rennin. 

Lactalbumin. — Lactalbumin, one of the components of whey 
protein, has the following composition: C. 52.19, H. 7.18, N. 15.77, 
S. 1.73, O. 23.13%. 2 When compared to casein, the most strik- 
ing differences are that it contains more sulphur and no phos- 
phorus. 

Lactoglobulin. — Lactoglobulin is very similar in its composition 

1 Van Slykeand Bosworth: Jour. Biol. Chem., xiv, 1913, 231. 

2 Hammarsten: Textbook of Phys. Chem., N. Y., 1912, 615. 

3 Bosworth and Van Slyke: Am. Jour. Dis. Children, 1914, vii, 298. 

4 Osborne and Quest: Jour. Biol. Chem., lx, 333. 

8 Raudnitz: Sommerf eld's Handbuch der Milchkinde, Wiesbaden, 1909. 



156 DISEASES OF NUTRITION 

to serum globulin. It is present in only small amounts in normal 
milk, but in larger amounts in colostrum. 1 

Extractives. — There are traces of urea, creatine, creatinine, 
hypoxanthine (?) and cholesterine in cow's milk. 2 

Whey. — Whey is an opalescent solution which remains after the 
coagulation of casein. It contains lactalbumin, lactoglobulin and 
extractives. Most of the solid portion of the whey of cow's milk is 
lactalbumin, while the rest, a small part, is divided among the 
other components. Although the analyses of whey are essentially 
the same as the analyses of lactalbumin, they are reported in a 
separate paragraph. The whey from cow's milk, according to 
Konig 3 contains: water 93.8%, total ash 0.44%. The ash con- 
tains K 2 30.77%, Na 2 13.75, CaO 19.25, Mg 0.036, F2O3 0.55, 
P2O5 17.05, S0 3 2.73, CL 15.15. 

Fat. — The percentage of fat in the mixed milk of herds may be 
maintained at 4% by carefully testing and selecting the cows. It is 
such 4% milk that should be used in infant feeding. The problems 
incident to maintaining the percentage of fats at the required 
amount do not concern the pediatrician, and, therefore, will not be 
considered. 

The fat droplets are exceedingly small. Their diameter varies 
from 0.0024 to 0.0046 m. m. There are 1.06 to 5.75 millions of fat 
drops to the cubic m. m. 4 It is possible that the fat droplets are 
maintained in a state of emulsion because they are surrounded 
by a covering of casein which prevents the globules from uniting 
with one another, 5 or that they are surrounded by a mem- 
brane. 6 

The fat of cow's milk is chiefly of olein and palmitin. It also 
contains triglycerides, butyric acid, myristic acid, stearic acid, 
small amounts of lauric acid, arachidic acid and dioxystearic acid, 
as well as caproic acid, traces of caprylic acid and capric acid. 7 
The fat of milk contains small quantities of lecithin, cholesterin, 
and a yellow coloring matter. It is possible that the quality of the 
food may influence the composition of the fat. 

Lactose. — Milk sugar is easily soluble in water and does not 
ferment with pure yeast. The extreme variations in the per- 
centage of milk sugar in cow's milk are 2.11% and 6.12%, the 

1 Sebelien: quoted by Voltz in Oppenheimer's Handb. loc. cit., p. 390. 
8 Hammarsten: Textbook of Phys. Chem., N. Y., 1912. 

5 Konig: loc. cit. 

4 Woll: Wisconsin Exp. Station, vi, 1892. 

6 Quincke: Pfluger's Arch. xix. 

6 Abderhalden and Voltz : Zeitschr. f. phys. Chem. lix. 

7 Hammarsten: loc. cit. 



AND INFANT FEEDING 



157 



average being 4.88%, * according to some authors, and 4.60% 
according to others. 2 

Lecithin. — Cow's milk contains between 0.048 gm. and 0.058 gm. 
of lecithin. 3 

Some investigators maintain, however, that these figures repre- 
sent a mixture of lecithin and kephalin. 4 

Salts. — The total ash in cow's milk is generally given as 0.7%, 
the extreme limits being 0.6% and 1.0%. 5 

TABLE 34 
Percentage of Salts in Cow's Milk in 100 Parts of Ash 



Bunge 



Abder- 
halden 4 



Schloss 4 



Soldner 



Pelka 4 



Rich- 
mond 9 



K 2 0. 

Na 2 0. 

CaO. 

MgO 

Fe 2 3 

P2O5. 

(CL) 



22.14 
13.91 
20.05 
2.63 
0.04 
24.75 
21.27 



22.40 

12.25 

21.07 

2.91 

24.10 
17.25 



24.74 

10.79 

21.35 

2.71 

29.54 
13.63 



24.96 
6.16 

22.25 
2.71 

32.27 
10.86 



23.75 
15.36 
20.37 



27.13 
14.67 



28.71 
6.67 

20.27 

2.80 

.40 

29.33 

14.00 



One liter of cow's milk contains in grams: 



Soldner 5 



Schloss 4 



K 2 . 

Na 2 0. 
CaO. 
MgO. 
P 2 5 . 
CL. . 



1.72-1.885 

0.51-0.465 

1.98-1.72 

0.20-0.205 

1.82-2.437 

0.98-0.82 



1.849 
0.861 
1.650 
0.215 
2.183 
1.091 



100 grams of the Ash of Cream contains in grams: 




1 Leach: loc. cit. 

2 Fleischmann: Lehrbuch der Milchwirtschaft, Bremen, 1898, xi, 43, quoted 
by Czerny and Keller, I, 437. 

3 Bunge: Zeitschr. f. Biologie, 1874, x, 309. 

4 Schloss: Uber Sauglings-Ernahrung, Berlin, 1912, 55. 

5 Soldner: Die Landwirthsch. Versuchstat, 1888, xxxv, 361, quoted from 
Voltz in Oppenheimer's Handbuch, III, I, 398. 

6 Richmond: Dairy Chemistry, Phila., 1899. 

7 Schloss: loc. cit. 



158 DISEASES OF NUTRITION 

Citric Acid. — Cow's milk contains about 0.2% of citric acid. 1 
Milk conducts electric currents because of the presence of salts 
of various kinds. The electrical conductivity of cow's milk is 
43.8.11-4, and of human milk 22.6. 10 -4. 2 Koppe concludes from 
these figures that 58% of the molecules in cow's milk and 26% of 
those in human milk are dissociated. 

FROZEN MILK 

Very little is known as to the chemical changes which take place 
in milk when it is frozen. It is supposed by some investigators 
that the casein is changed by the freezing into a more permanent 
compound. 3 Mai 4 concluded, however, that the freezing and 
thawing of milk causes no permanent change in its composition. 

Pennington 5 and her collaborators found very definite changes 
in milk after freezing. They found that when the milk is held at a 
temperature of 0° C. (length of time not stated), there is pro- 
teolysis of the casein, which is primarily of bacterial origin, and 
proteolysis of the lactalbumin, due primarily to the native enzymes 
of the milk. The action of these two agents together is more 
rapid than that of either agent alone. The bacteria and enzymes 
may break down the true protein and carry the breaking down 
through peptones even to amino acids. There is a fermentation of 
lactose with the formation of lactic acid, which is largely, if not 
exclusively, due to bacterial action. The fat, so far as can be 
determined, is not affected except by the action of bacteria. 

Some bacteria disappear from the milk while it is frozen, while 
others may increase rapidly, especially if the milk is raw. The 
rate of increase in the number of bacteria depends upon their 
previous surroundings and upon the rapidity with which they 
become acclimated to their surroundings. There is apt to be very 
little increase in the first four or five days, after which there is a 
very rapid increase in numbers. There is no information concern- 
ing the chemical changes which take place in milk that has been 
frozen from only twenty-four hours to forty-eight hours. The 
predominating organisms which they found were the micrococcus 

1 Soldner: Zeitschr. Biol., 1896, xxxiii, 43, 535. 

2 Koeppe: Jahrb. f. Kinderh., 1898, xlvii, 389. 

3 Engling: Landw. Vers. Stat., 1888, xxxi, 391; Siegfried and Bischoff : quoted 
by Raudnitz in Sommerf eld's Handbuch, 201. 

4 Mai: Z. Nahr. Genussm., xxiii, 250 from chemical abstr., Sept. 20, 1912. 

5 Pennington, Hepburn, Witner, Stafford and Burrell: Jour, of Biol. Chem., 
1913, xvi, 331. See also Pennington: Jour. Biol. Chem., 1908, iv, 353; Hep- 
burn: Jour, of the Franklin Ins., 1911, clxxii, 187. 



AND INFANT FEEDING 



159 



TABLE 35 

Comparative Composition of Milks of Different Animals Taken from 

Voltz x 



Milk 



Water 


Solids 


Fat 


Casein 


Total 

N. 


Sugar 


87.58 


12.42 


3.74 


0.80 


2.01 


6.37 


87.80 


12.20 


3.40 


2.70 


3.40 


4.70 


82.30 


17.70 


7.70 




4.80 


4.40 


86.13 


13.87 


4.80 




3.03 


5.34 


86.55 


13.45 


3.15 


3.00 


3.90 


5.60 


87.60 


12.40 


5.38 


2.98 




3.26 


86.30 


13.70 


4.00 


3.60 


4.60 


4.30 


81.50 


18.50 


7.00 


4.30 


5.60 


5.00 


67.70 


32.30 


17.10 




10.90 


2.80 


90.58 


9.42 


1.14 




2.50 


5.87 


90.12 


9.88 


1.37 


0.79 


1.85 


6.19 


67.85 


32.15 


19.57 




3.09 


8.84 


90.43 


9.57 


4.51 








69.50 


30.50 


10.45 




15.54 


1.95 


41.11 


58.89 


45.80 




11.19 


1.33 


77.00 


23.00 


9.26 


4.15 


9.72 


3.11 


81.64 


18.36 


3.33 


3.11 


9.53 


4.91 


82.37 


17.63 


6.44 




6.09 


4.04 


50.47 


39.53 


20.00 




12.42 


5.63 



Ash 



Human 

Cow 

Buffalo 

Zebu (1 analysis) . 
Lama (3 analyses) 
Camel (7 analyses) 

Goat 

Sheep 

Reindeer 

Mare 

Donkey 

Elephant 

Hippopotamus 

(1 analysis) . . . 
Rabbit 

(1 analysis) . . . 
Guinea pig 

(1 analysis) . . . 
Dog (8 analyses) . 
Cat 

Pig 

Blue Whale 



0.3 2 

0.7 3 

0.8 4 

0.7 5 

0.8 6 

0.7 7 

0.8 s 

0.9 9 

1.50 10 

0.36 " 

0.47 12 

0.65 13 



2.56 14 

0.57 15 
0.91 16 

0.59 17 
0.59 18 

1.48 19 



1 Oppenheimer's Handbuch der Biochemie, iii, Jena, 1910, 403. 

2 J. Konig: D. mensch. Nahrungs u. Genussmittel 1904, Berlin, ii, 598. 

3 Kirschner: Hand. d. Milch wirtschaft, Berlin, 1907, pp. 7 and 40. 

4 Kirschner (see above) . 

5 Konig (see above) . 

6 Konig (see above). 

7 Barthe: quoted in Malys Jahresber., 1906, 230. 

8 Kirschner (see above) . 

9 Kirschner (see above) . 

10 Fleischmann: Lehrb. d. Milchwirtschaft, 3rd ed., Leipzig, 1901, 67. 

11 Kirschner (see above). 

12 Kirschner (see above) . 

13 Hammarsten. 

14 Konig (see above). 

15 Konig (see above). 

16 Konig (see above). 

17 Camaille, C. R. 63, 692. 

18 Hammarsten. 

19 Backhans quoted in Maly's Jb. 1906, 299. 



160 



DISEASES OF NUTRITION 



aurantiacus (Cohn), and the micrococcus ovalis (Eseherich) both 
of which belong to the acid forming group. 

Rosenau L found that freezing milk for forty-eight hours did not 
influence its restraining action on the growth of the typhoid bacil- 
lus, but destroyed it for the B. lactis aerogenes. 



GOAT S MILK 

Goats are seldom infected with tuberculosis. 2 This does not 
mean, however, that they are immune and never have the disease. 

The goat may secrete ten times its own weight in milk in a 
year's time. 3 It produces the most milk during the hot summer 
months. 

The composition of goat's milk as given by various authors is 
as follows: 

TABLE 36 



Per cent. 


Ellen- 


Hucho 5 


Abder- 


Voelcker 7 


A nder- 


Schaf- 


Sleineg- 


of 


burger 4 


halden 6 


1 2 3 


egg* 


fer' 


ger 


Fat 


6-7 


2.50 to 
5.10 


2.93 


7.02 7.11 7.34 


4.6 


2.14 to 
4.72 


3.25 


Lactose. . . 


4.5 


3.76- 
5.46 


3.92 


5.28 4.68 5.99 


4.3 


2.07 to 

4.77 


2.80 


Casein .... 


2.8 




2.56 










Albumen. . 


0.51 




0.58 




1.03 






Total 
















protein . 


3.35 


2.25- 
3.89 


3.14 


4.67 3.94 3.19 


3.5 


2.3 to 
4.38 


3.92 


Ash 


0.895 


0.72- 
0.98 




1.01 0.79 0.77 


0.51- 
0.93 


0.63 


0.63 



The composition of goat's milk is very similar to that of cow's 
milk. It is different, however, in that it is pure white instead of 
golden white in color. Goat's milk has a characteristic odor when 
it is milked in the stable and the odor of the animals pervades the 

1 Rosenau: Hygienic Laboratory, Bulletin No. 56, Washington, 1909, 487. 
2 Richter: Berliner klin. Wochenschr., 1888, No. 18; Schwartz: Deutschr. 
med. Wochenschr., 1896, No. 40. 

3 Fleischmann: Lehrbuch d. Milch wirtschaft, 2nd ed., 1898, 65 (C. & K.) 

4 Ellenburger: Arch. f. physiol., 1899, p. 48. 

6 Hucho: Yahresber f. physiol. Chemie, 1899, xxvii, 440. 

6 Abderhalden : Zeitschr. f. physiol. Chemie, 1899, xxvii, 440. 

7 Voelcker: Milchzeitung, 1881, x, 151 (3 goats). 

8 Anderegg: Sandw. Wochenbl., 1893, xix, 290 and 330 (C. & K.) 

9 Schaffer: Schweizer, Wochenschr., f. Pharmacie, xxxi, 58 (C. & K.) 



AND INFANT FEEDING 



161 



air. This odor is more marked when the male is present in the 
same stall as the female. 

The fat drops in goat's milk are somewhat smaller than those in 
cow's milk. The casein coagulates more quickly with rennin than 
does that of cow's milk. 1 The casein precipitates out in compact 
masses, which are colored white and have a fine structure. When 
this casein undergoes pepsin-hydrochloric acid digestion, 12% re- 
mains undigested. 

Konig 2 found the average composition and the extreme varia- 
tions in 100 analyses to be as follows: 





TABLE 37 




Water 


Average 
86.88 % 
4.07 % 
4.63 % 
3.76 % 
0.85 % 
1.030% 


Variations 
82.02 -90.16% 


Fat 


2.29 - 7.55% 


Lactose 


2.80 - 5.72% 


Protein 


3.32 - 6.50% 


Ash 


0.35 - 1.36 


Specific gravity .... 


1.028- 1.036 



The composition of goat's milk is influenced by the same factors 
and in the same manner as cow's milk. 



1 Devarda: Landw. Versuchsst. xlvii, 416; Steinegger: Milch Ztg., 1898, 
No. 23. Quoted by Burr in Sommerfeld, — loc. cit. 

2 Konig: Molkerei-Ztg. Hildesheim, 1897, pp. 617, 635, 653. 



162 DISEASES OF NUTRITION 



CHAPTER XIV 
COW'S MILK: BACTERIOLOGY AND CHEMICAL TESTS 1 

There are two types of bacteria found in milk, the non-pathogenic 
and the pathogenic. The ideal milk would be one which contained 
no bacteria but this is very difficult to obtain because bacteria find 
their way into the udder through the opening in the teat. These 
bacteria are washed out in the fore-milk which is rejected for this 
reason, by those producing clean milk. 

The commonest bacteria in milk are those producing souring, 
of which the lactic acid bacteria are the most common. These 
bacteria produce so much acid in milk that they gradually crowd 
out other organisms which cannot grow in the acid surroundings. 
Lactic acid bacteria are not found in milk when it leaves the udder, 
but enter the milk when it is exposed to air. The commonest lactic 
acid forming bacteria are the Bacillus lactis acidi or Streptococcus 
lacticus. They grow best in anaerobic media. A less common 
form is the B. lactis aerogenes. 

Of the bacteria which may produce disease in man and cause 
souring of milk, the colon bacillus is common. It is derived from 
the manure of the cow. Streptococci, which cause inflammation 
of the udder of the cow, may sour the milk and cause disease in 
those drinking it. There are some one hundred varieties of bacteria 
which may lead to lactic acid fermentation and souring of milk. 

The class of organisms known as putrefactive bacteria may im- 
part a bad odor to the milk and cause diarrhea in children either 
through their own action or by the products of their activity. 
They enter the milk in manure and filth. They may liquefy and 
digest casein. 

Another group of bacteria apparently has no action on the milk 
and is not harmful to the consumer. 

Butyric acid bacteria form butyric acid by splitting up the fat in 
rancid butter. Yellow, red, blue, brown and green milk are rarely 
seen and the particular coloration is due to changes produced in 
the milk by special bacteria. A turnip taste is often given milk by 
the B. fcetidus lactis. Slimy milk, and bitter, stringy, and soapy 

1 Winslow: The Production and Handling of Clean Milk, New York, 1909, 
has been freely used in this section. 



AND INFANT FEEDING 163 

milk are due to other special bacteria. Bitter milk may, however, 
be produced by other causes than the growth of bacteria, as by 
certain foods which the cow may eat (lupines, ragweed, wormwood, 
cabbages, raw Swedish turnips). Inflammation of the udder or 
garget may also cause the milk to be bitter. - 

Red milk may be due either to blood or the cow's eating large 
amounts of sedges, rushes, madder root, alkalet, field horsetail, 
meadow saffron, and knot grass. A red yeast may cause the cream 
to turn pink after standing two days. 

Slimy milk may be due to pus or to the B. lactis viscosus, which 
comes chiefly from water and dust. 

Pathogenic Bacteria in Cow's Milk. 1 — The tubercle bacillus is 
found frequently in cow's milk when the animal is affected. with 
tuberculosis of the udder. It is also found in milk when the udder 
is healthy and there is disease in other parts of the body, viz., if 
the bowel or uterus, the excretions of which fall into the milk. 
The secretion from a diseased lung is swallowed and may be 
spattered into the milk pail. The tubercle bacillus may also get 
into milk from consumptives who are working around the cattle, 
either from their hands or expectoration. 

Theobald Smith 2 and others have shown that there is a differ- 
ence between the human and bovine type of the tubercle bacillus. 
Recent pathological investigations show that the bovine type of 
the tubercle bacillus may be the cause of tuberculosis in human 
beings, especially in the infant and young child. 3 

Other pathogenic bacteria which may grow in milk and have 
been the etiological cause of epidemics are the typhoid bacillus, the 
diphtheria bacillus, the streptococcus, and the organism that causes 
scarlet fever. The milk is usually infected after it has been milked 
by the hands of the milker, the air and dust in the stable, the milk 
pail, the water supply, the milk cooler, cans or bottles. The 
organisms get into the milk from the outside. 

Other organisms which have not been reported as the cause of 
epidemics, but which are of pathological significance in cow's milk 
are the dysentery bacillus (both Shiga and Flexner types), the gas 
bacillus, the staphylococcus, bacteria of the colon group, the 
bacillus of anthrax, actinomyces, and the organisms of cow pox, 
hydrophobia, foot-and-mouth disease and cholera. 

1 Weber, A.: In Sommerf eld's Hand, der Milchkunde, Wiesbaden, 1909, 405, 
is used freely in this section. The original may be consulted for the literature. 

2 Smith, Theobald: U. S. Dep't Agric. Bureau of Animal Ind., 12 and 13, 
Washington, 1897; Jour. Exp. Med., 1893, hi. 

3 Von Behring and Smith, T. : British Royal Commission on Tuberculosis. 



164 DISEASES OF NUTRITION 

"Milk sickness" * is a disease of sparsely settled communities 
which has been described only in America. It is due to a motile rod 
with nagella, the Bacillus lactimorbi, which has been demonstrated 
by Jordan and Harris. 2 In cattle it causes the disease known as 
" trembles." It is very fatal to man. 

The bacillus of contagious abortion 3 has recently been studied 
in milk, but its pathological significance to man is as yet unknown. 
Larson and Sedgwick 4 have found that the blood of many women 
who have aborted gives the complement fixation test to the Bacillus 
abortus as does the blood of many children. 

Caloric Value of Milk. — It is obvious that the caloric value 
of milk depends upon its composition. Since the composition of 
cow's milk varies considerably the caloric value also varies. The 
figures most generally accepted are those of Rubner who found 
that 1000 grams of milk gave between 622 and 690 calories. Heub- 
ner uses 670 calories as the average caloric value of cow's milk. 

Milk Preservatives. 5 — The most commonly used preservatives 
are formaldehyde, borax and boric acid. Occasionally salicylic 
acid and sodium carbonate are employed. 

Formaldehyde may be detected in milk in the following man- 
ner: Place about twenty cubic centimeters of milk in a small glass 
vessel, dilute with an equal volume of water, and add commercial 
sulphuric acid, allowing it to flow slowly down the inside of the 
vessel. If formaldehyde is present a purple color will appear at 
the junction of the acid and milk. 

Boric acid or borax are detected by adding a drop or two of 
hydrochloric acid to a few drops of milk in a white dish and then 
several drops of a saturated alcoholic solution of turmeric. The 
dish is then heated gently for a few minutes and, if boric acid or 
borax are present, a pink or dark red color will appear. A dark 
blue-green should appear when the dish is cooled and a drop of 
ammonia added. 

Sodium carbonate is detected by adding an equal volume of 
alcohol and then two drops of a 1% solution of rosolic acid to the 
suspected sample of milk. If sodium carbonate is present a red- 
rose color will appear. The test may be performed with more 

1 McCoy: Treasury Dep't, Hygienic Laboratory Bull. 56, Wash., 1908, 
217. 

2 Jordan and Harris: Jour. A. M. A., 1908, L. 1665. 

3 Fabyan: Jour, of Med. Research, xxvi, No. 3; xxviii, No. 1; Larson: Jour. 
Inf. Dis., 1912, 178. 

4 Larson and Sedgwick: Am. Jour. Dis. Children, 1913, vi, 326. 

5 Taken from K. Winslow: The Production and Handling of Clean Milk, 
N. Y., 2nd Edition, 1909. 



AND INFANT FEEDING 165 

certainty if a control test is made at the same time with a sample 
of milk known to be pure. 

Salicylic acid is rarely used as a preservative. It may be de- 
tected by adding a few drops of sulphuric acid to a small quantity 
of milk and then shaking gently with a mixture of equal parts of 
ether and petrolic ether. Equal volumes of acidulated milk and the 
ether mixture should be taken. The upper ethereal solution is 
poured off after standing for several hours and the remaining liquid 
is evaporated in a porcelain dish. A few drops of water and a 
drop of ferric chlorid solution will produce a violet or purple color 
on being added to the solution if salicylic acid is present. 

Babcock test (see page 216). 

Estimation of total solids (see page 216). 



166 DISEASES OF NUTRITION 



CHAPTER XV 

STERILIZATION, BOILING AND PASTEURIZATION OF 

MILK 

The term, " sterilization," should never be applied to the proc- 
esses used in the preparation of milk for the feeding of infants, 
because the milk is never rendered bacteriologically sterile by 
them. The term "pasteurization," as it is ordinarily used, is 
indefinite and misleading. It should always be stated at what 
temperature the milk is heated and how long it is kept at this 
temperature; otherwise, it means nothing. 

THE CHANGES PRODUCED IN MILK BY HEAT 

Appearance, Taste and Smell. — A well-marked scum, or pel- 
licle, develops on the surface of boiled milk. This may begin to 
develop at as low a temperature as 122° F. (50° C.) (Pfaundler and 
Schlossmann). 1 This is due to the disassociation of the casein 
compounds as the result of drying. Its composition is : 

Fatty matter 45.42% 

Casein and albuminoid .... 50.86% 

Ash 3.72% (Rosenau) 

Changes in the taste and smell may develop at as low a tem- 
perature as 158° F. (70° C.) (Sommerfeld), 3 but are usually not 
marked unless the milk is brought nearly to the boiling point. 
Prolonged boiling changes the color toward brown, the amount of 
change depending on the duration of the boiling. The change in 
color is due to the caramelization of the sugar. Heating at 150° F. 
(65° C), or over, for half an hour, materially delays or entirely 
prevents the rising of cream. This is because the normal agglutina- 
tion of the fat droplets is broken down and they are more homoge- 
neously distributed throughout the fluid (Rosenau). 2 

1 Pfaundler and Schlossmann: The Diseases of Children, 1908, i, 303. 

2 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

3 Sommerfeld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. 



AND INFANT FEEDING 167 

Composition. — When milk is boiled there is a partial fixation 
of the calcium salts, which are probably precipitated in the form 
of tricalcium phosphate (Kastle and Roberts). 1 There is also 
a precipitation of the magnesium salts (Rosenau). 2 There is a 
diminution in the amount of organic and an increase in that of 
inorganic phosphorus (Rosenau). 2 About one-third of the citric 
acid is precipitated in the form of tricalcium citrate (Pfaundler and 
Schlossmann. 3 About 90% of the carbon dioxid and 50% of the 
oxygen and nitrogen are also driven off (Pfaundler and Schloss- 
mann). 3 There is also a certain amount of decomposition of the 
compounds of casein into casein and its base. The casein is ren- 
dered less easy of coagulation by rennin and is more slowly and 
imperfectly acted on by pepsin and pancreatin (Rosenau). 2 It is 
difficult to understand why this is so, because the precipitation of 
the soluble albumins, which act as protective colloids (Alexander 
and Bullowa), 4 by boiling, should make the coagulation of the 
casein easier. The curd produced by the action of acids (Pfaundler 
and Schlossmann) 3 and rennin (Rosenau) 2 is, moreover, softer 
and more flocculent than that in raw milk. The soluble albumins 
are entirely precipitated (Sommerfeld). 5 

There are no available data as to the temperature at which the 
changes which take place in boiled milk first appear, except in the 
case of the soluble albumins. Sommerfeld 5 quotes Steward to the 
effect that heating at 149° F. (65° C.) for thirty minutes dimin- 
ishes them, and that thirty minutes at 176° F. (80° C.) completely 
destroys them. Schlossmann 6 found a slight diminution in the 
solubility of the albumins at 158° F. (69° C.) and Solomin 7 states 
that there is an "apparent" beginning of clotting of milk albumin 
by heating at 140° F. (60° C.) for fifteen minutes, but he is not 
sure whether or not it is really the lactalbumin which is involved. 
It is not far wrong to conclude, therefore, with Hippius, 8 that the 
heating of milk at 149° F. (65° C.) for thirty minutes causes no 
noteworthy changes in the chemical composition of the milk. 

Ferments. — According to Hippius, 8 the proteolytic ferment 
of cow's milk is unchanged by heating for one hour at 140° F. 

1 Kastle and Roberts: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909. 

2 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

3 Pfaundler and Schlossmann : The Diseases of Children, 1908, i, 303. 

4 Alexander and Bullowa: Arch. Pediat., 1910, xxvii, 18. 

5 Sommerfeld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. 

6 Schlossmann: Ztschr. f. physiol. Chem., 1896-7, xxii, 197. 

7 Solomin: Arch. f. Hyg., 1897, xxviii, 43. 

8 Hippius: Jahrb. f. Kinderheilk., 1905, bd, 365. 



168 DISEASES OF NUTRITION 

(60° C.) or for one-half hour at 149° F. (65° C), but is destroyed by 
boiling, while the oxidizing ferment is unchanged by heating, even 
for several hours, at from 140° F. (60° C.) to 149° F. (65° C), but is 
destroyed by one hour at 169° F. (76° C). Kastle and Porch 1 
have shown, moreover, that the peroxidases are somewhat in- 
creased by heating at 140° F. (60° C). 

Bactericidal Action. — The bactericidal power of milk is still 
considerable after continued exposure to temperatures of from 
140° F. (60° C.) to 149° F. (65° C), but is destroyed by boiling 
(Hippius). 2 The alexins are affected in the same way (Von Behr- 
ing). 3 

Precipitin Reaction. — The heating of milk, even for one hour 
at 248° F. (120° C.) in the autoclave, does not diminish the precip- 
itin reaction (Hippius). 2 

Bacteria and Their Products. — It has been proved by many 
investigators that the typhoid bacillus, the diphtheria bacillus, 
the dysentery bacillus and the cholera vibrio, as well as the other 
pathogenic non-spore-bearing organisms most often found in 
milk, are destroyed in milk by heating at 140° F. (60° C.) for 
twenty minutes (Rosenau) 4 and at higher temperatures for 
shorter lengths of time. Butyric acid bacteria are destroyed at 
from 212° F. to 216° F. (100° C. to 102.2° C.) for from one to two 
minutes (Sommerfeld). 5 The spores of the peptonizing bacteria 
are much more resistant, however, some of them withstanding 
boiling for one hour (Sommerfeld). 5 

Since the investigations of Fltigge, 6 in 1894, who found spore- 
bearing peptonizing bacteria developing in milk heated at 158° F. 
(70° C.) for thirty minutes and forming highly toxic substances 
therein, it has been very generally believed that the destruction 
of the lactic acid bacteria by pasteurization resulted in the un- 
hindered growth of undesirable, proteolytic bacteria, which pro- 
duced toxins and other poisonous products, and that pasteurized 
milk putrefied rather than soured. It has also been supposed that 
bacteria multiply more rapidly in pasteurized than in raw milk. 
Ayers and Johnson 7 recently found, however, that many acid- 

1 Kastle and Porch: Jour. Biol. Chem., 1908, iv, 301. 

2 Hippius: Jahrb. f. Kinderheilk., 1905, lxi, 365. 

3 Von Behring: Therap. d. Gegenw., 1904, N. F., vi, 1. 

4 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

5 Sommerfeld: Handbuch der Milchkunde, J. F. Bergman, Wiesbaden, 1909. 

6 Fltigge: Ztschr. f. Hyg., 1894, xvii, 272. 

7 Ayers and Johnson: Bulletin 126, U. S. Dept. Agric, Bureau of Animal 
Industry. 



AND INFANT FEEDING 169 

forming bacteria are not destroyed below 168° F. (75.6° C.) and 
that, in consequence, pasteurized milk turns sour in the same way 
as raw milk, although the process is somewhat delayed. They 
found that there were fewer peptonizing bacteria in pasteurized 
than in raw milk and that they did not multiply rapidly. The 
numerical relations of the acid-forming bacteria, the peptonizing 
(putrefactive) bacteria and the inert bacteria were practically the 
same as in clean, raw milk, and the acid development in an effi- 
ciently pasteurized milk was about the same as in clean, raw milk. 
They also found that the rate of multiplication of bacteria de- 
pended on the number of bacteria present in the milk. The rapid- 
ity of multiplication was the same in pasteurized as in raw milk 
containing the same number of bacteria and more rapid in both 
than in dirty milk. 

It is generally believed that the heating of milk, even to boiling, 
has no effect on the toxic products of bacterial growth which it 
may contain. This belief is in part justified and in part unwar- 
ranted. The true bacterial toxins are thermolabile, many of them 
being rendered inert at 140° F. (60° C). Bacterial endotoxins may 
be very resistant, however, that of the B. coli communis being, for 
example, unaffected by fifteen minutes at 272° F. (134° C.) . There 
is no doubt that the spore-bearing organisms can set up putrefac- 
tive and proteolytic changes in milk and produce poisons as the 
result. The nature of these poisons is not known. Their connec- 
tion with "milk poisoning" has been inferred, not demonstrated. 
Moreover, as far as is known, the true bacterial toxins play but 
little, if any, role in milk poisoning (Rosenau). 1 

THE EFFECTS OF THE HEATING OF MILK ON ITS DIGESTIBILITY AND 
ON ITS VALUE AS A FOOD FOR INFANTS 

Experiments in Artificial Digestion. — The evidence derived 
from artificial digestion experiments as to the comparative di- 
gestibility of boiled or sterilized and raw milk is inconclusive; there 
is little or none as to that of pasteurized and raw milk. The 
casein is rendered less easy of coagulation by rennin, but the curd 
produced by the action of acids (Pfaundler and Schlossmann) 2 
and rennin (Rosenau) * is softer and more flocculent than that in 
raw milk. De Jager 3 concluded that raw milk was the more 

1 Rosenau: Bulletin 56, Hyg. Lab., Pub. Health Service, 1909; Circular 153, 
U. S. Dept. Agric, Bureau of Animal Industry, 1910. 

2 Pfaundler and Schlossmann: The Diseases of Children, 1908, i, 303. 

3 DeJager: Centralbl. f. d. med. Wissensch., 1896, xxxiv, 145. 



170 DISEASES OF NUTRITION 

easily digested, while Fleischmann 1 decided that sterilized milk 
was more easily acted on by the digestive ferments than raw milk. 
Jemma 2 and Michael 3 found that sterilization did not impair 
the digestibility of milk. 

Animal Experiments. — Almost all experiments agree in show- 
ing that all animals do better when fed on the raw than on the 
cooked milk of their own species. Von Brunning 4 has collected 
reports of experiments of feeding animals with the raw and cooked 
milk of another animal. The results were the same in all, namely, 
that, when fed on the milk of another animal, the young animals 
did better when the milk was cooked than when it was raw. 
Raudnitz 5 fed dogs on raw and on sterilized milk and found 
that the fat and nitrogen were better utilized with the raw than 
with the sterilized milk. Lane-Claypon 6 has reviewed the 
literature of this subject very carefully and done considerable 
experimental work herself. She concludes from her own work that 
there is no evidence to show that, in the case of calves, boiled 
cow's milk is inferior to raw cow's milk and that, if young ani- 
mals are fed upon the milk of a suitable foreign species, they 
appear to thrive somewhat better if the milk is given boiled 
than raw. 

Experiments on Babies. — Lane-Claypon 6 has recently summed 
up the work which has been done in feeding babies on raw and 
cooked human milk and arrives at the conclusion that the data 
available are insufficient to warrant any definite decision as to the 
comparative nutritive value of raw and boiled human milk for 
babies. There is no doubt, however, that many babies thrive well 
on boiled human milk. 

Very few metabolism experiments have been done in babies as to 
the relative utilization of raw and cooked cow's milk and these are 
incomplete and fragmentary. They show, however, little differ- 
ence in the results with the two foods. Muller and Cronheim 7 
found that the calcium was less well utilized when the milk was 
cooked, but Finkelstein 8 says that their methods are open to 

1 Fleischmann: Quoted by Doane and Price, Bulletin 77 of the Maryland 
Agricultural Experiment Station, 1901. 

2 Jemma: Dietet. and Hyg. Gaz., 1900, xvi, 83 

3 Michael: Hyg. Rundschau, 1899, ix, 200. 

4 Von Brunning : Quoted by Finkelstein. See nooe 8. 

5 Raundnitz: Ztschr. f. physiol. Chem., 1890, xiv, 1. 

6 Lane-Claypon: Report to Local Government Board, England, N. S. 
No. 63. 

7 Muller and Cronheim: Therap. Monatsh., 1903, xvii, 340. 

8 Finkelstein: Therap. Monatsh., 1907, xxi, 508. 



AND INFANT FEEDING 171 

criticism. Krasnogorsky, 1 on the other hand, states that the 
iron is better utilized from cooked than from raw milk. 

It has been generally believed in this country until very recently 
that babies fed continuously on cooked milk do not thrive so well 
as those fed on raw milk and that the cooking of milk predisposes 
to the development of the diseases of nutrition, while physicians in 
Europe have believed that babies thrive as well, or perhaps better, 
on cooked than on raw milk. There is, however, relatively little 
evidence on either side. Finkelstein 2 studied sixty well and 
fifty-three sick babies and concluded that there was no evident 
difference in the results with raw and with cooked milk and that 
neither the gain of the healthy nor the healing of the sick was 
visibly aided by raw milk. He quotes Czerny as having obtained 
the same results and states on the authority of an oral communica- 
tion that the experiment of feeding raw and cooked milk to a large 
series of babies had been tried for three years at the Waisenhaus in 
Stockholm and that no difference in the results from the two methods 
had been noted. Variot 3 states that during the twelve years 
ending in 1904 more than 3,000 infants were fed at the dispensary 
of the goutte de lait of Belleville with milk heated at 226° F. (108° 
C.) and that rachitis did not develop in any, but that anemia was 
not uncommon. Scurvy is not mentioned. Carel 4 states that of 
210 infants belonging to the laboring class of Paris fed on raw milk, 
31.8% developed rickets, while of 373 infants of the same class fed 
on cooked milk only 15% developed rickets and none scurvy. 
Sill 5 of New York reports, on the other hand, that he found signs 
of rickets or scurvy in 97% of 179 consecutive cases of infants fed 
on pasteurized or sterilized milk. The statistics of the French 
observers are open to considerable doubt, however, because, unless 
the French infants of the hospital class are very different from the 
American, 80% of them show signs of rickets, no matter on what 
they are fed, while scurvy was not sufficiently well known in 
France at that time to be recognized unless of a most extreme type. 
Lane-Claypon 6 has recently studied a series of babies, part of 
whom were fed on breast-milk and part on boiled cow's milk, at 
the Municipal Infant Consultation in the Naunyn Strasse in Ber- 
lin. She found that the deficit in weight in the babies fed on 

Krasnogorsky: Jahrb. f. Kinderheilk., 1906, lxiv, 651. 

2 Finkelstein: Therap. Monatsh., 1907, xxi, 508. 

3 Variot: Compt. rend. Acad. d. Sc, 1904, cxxxix, 1002. 

4 Carel: Le lait sterilise^ These de Paris, 1902-3. 

5 Sill: Med. Rec, New York, 1902, brii, 1016. 

6 Lane-Claypon: Report to Local Government Board, England, N. S. 
No. 63. 



172 DISEASES OF NUTRITION 

boiled cow's milk below those fed upon the breast was not as 
much as 10% at any period. She also sums up the literature of the 
subject in her paper. 

It is very difficult to determine what influence the heating of 
milk, at whatever temperature, has on the development of rickets, 
because the exact etiology of rickets is at present so obscure. It is 
probable that heredity, improper hygienic surroundings and 
improper food all play a part in its production. It is extremely 
difficult to know in an individual case which is the most important 
element and almost impossible to determine it in large series of 
cases. Our present statistics as to the relative frequency of rachi- 
tis in those fed on heated and those fed on raw milk are not ac- 
curate enough to form the basis of any definite conclusions on this 
point, because they do not give any accurate data as to the other 
possible etiologic conditions. 

The evidence to prove that the heating of milk produces scurvy 
is stronger than in the case of rickets, but not at all conclusive, 
this evidence being the fact that all large series of cases of scurvy 
show that a considerable proportion of the patients were fed on 
heated milk, more of them, however, on sterilized, boiled or 
scalded, than on pasteurized milk. It is impossible to prove, 
however, that it was the heating of the milk and not the composi- 
tion of the food which caused the scurvy in these babies. It is 
evident that when an individual baby is fed on a heated, modified 
milk it is impossible to know, if scurvy develops, whether it is due 
in the special case to the heating or to the composition of the milk. 
It can be only a matter of opinion. A decision can be reached 
only by the analysis of large series of cases. It may even then be 
difficult, as is shown by the fact that the series collected by the 
American Pediatric Society, the largest single series on record, is 
quoted both for and against the etiologic influence of the heating 
of milk in the production of scurvy. Further evidence against the 
heating of milk causing scurvy is that scurvy sometimes develops 
in the breast-fed and in babies fed on raw milk. Still further 
evidence are Plantenza's l observations that, although scurvy 
developed more frequently in babies fed on heated milk which 
was not used at once than on raw milk, it did not develop when 
fresh milk was heated and used at once. 

It has been asserted that the cooking of milk " devitalizes" it 
and thus renders it a less suitable food for infants. It is pre- 
sumable that what is meant by " devitalization" is the destruction 
of the ferments. The point at which this occurs has already been 
1 Plantenza: Arch. f. Kinderheilk., 1912, lviii, 155. 



AND INFANT FEEDING 173 

given, showing that they are not injured at temperatures below 
150° F. (65° C). There is no proof, however, that the ferments of 
milk play any part in the digestion and utilization of the milk, the 
only apparent foundation for the belief that they do being a state- 
ment of Marfan 1 in 1901 that "it is probable that the milk fer- 
ments act as stimulators and regulators of nutrition, and that they 
are identical in function with the ferments elaborated by the 
various tissues and are intended to compensate for the deficiency 
of the internal secretions of the new-born." This statement is 
founded entirely on analogies and hypotheses and not on experi- 
ments or facts. 

Cooking of Milk Advised as a Routine Measure. — The boiling 
and proper pasteurization of milk destroys the ordinary non-spore- 
bearing pathogenic microorganisms. The bacterial growth in 
pasteurized milk is the same as in clean, raw milk. The evidence 
at present available is insufficient to show whether cooked milk 
is more or less digestible than raw milk, whether babies thrive on it 
as well as on raw milk and whether or not it predisposes to the 
development of the diseases of nutrition. Granting that the cook- 
ing of milk does make it somewhat less digestible and that its 
continued use does predispose to the development of the diseases 
of nutrition, it is evident, nevertheless, that the disturbances 
which it causes are slight and insignificant in comparison with the 
diseases caused by milk contaminated with bacteria. All milk, 
except the cleanest, should, therefore, be cooked before being used 
as a food for infants. 

Pasteurization. — The higher the temperature at which milk is 
heated, the greater are the changes in its composition. While it is 
somewhat problematical how much influence these changes have 
on the development and well-being of the infant, it is the part of 
wisdom to avoid them as far as is consistent with the attainment 
of the object of cooking milk, that is, the destruction of pathogenic 
microorganisms. Pasteurization is therefore preferable to boiling. 
The temperature of the pasteurization should be, moreover, as 
low as is possible. Pasteurization at 140° F. (60° C.) for twenty 
minutes is efficient; lower temperatures are not. This temperature 
and time are, therefore, the ideal ones. At this temperature there 
is no change in the taste, odor or color of the milk, no noteworthy 
changes in the chemical composition are produced, the ferments 
and bactericidal action are unaffected and bacterial toxins and 
nonspore-bearing microorganisms are destroyed. 

There are three methods of commercial pasteurization in com- 
1 Marfan: Presse Med., 1901, ix, 13. 



174 DISEASES OF NUTRITION 

mon use: the flash method, the holding method and pasteuriza- 
tion in the bottle. The flash method consists in momentarily 
heating the milk to a temperature of approximately 170° F. (76.7° 
C.) by allowing it to flow in a film over heated metal pipes or coils 
and then at once chilling it. The holding method consists in 
heating the milk to between 140° F. (60° C.) and 155° F. (68° C.) 
and then placing the milk in a receptacle where it is held at approx- 
imately this temperature for from twenty minutes to an hour. 
The flash method has been repeatedly shown to be unreliable and 
should not be employed. The holding method is not so satisfactory 
as would at first appear, because, while the destruction of the 
bacteria in a small quantity of milk by heating it at 140° F. (60° C.) 
for twenty minutes is simple enough, it is very difficult to heat a 
large volume of milk to a definite temperature and hold it at that 
temperature for a given period of time. Schorer and Rosenau * 
have shown that under ordinary commercial conditions the tem- 
peratures expected were not attained. In their four experiments, 
two planned for 140° F. (60° C.) and two for 145° F. (62.7° C), 
from 99.4% to 99% of the bacteria were, nevertheless, destroyed. 
A certain number of pathogenic microorganisms, however, sur- 
vived. They conclude, therefore, that in order to be safe, pasteur- 
ization under commercial conditions should be at 145° F. (62.7° C.) 
for from thirty to forty-five minutes. Schorer 2 further concludes 
that the safest method for pasteurization is in the sealed bottle, 
allowing at least thirty minutes for heating to the temperature 
of pasteurization and then pasteurizing at 145° F. (62.7° C.) for 
thirty minutes. He also wisely advises that all commercial pasteur- 
ization shall be carried out under official supervision. 

It must never be forgotten that the pasteurization of milk does 
not do away with the necessity of taking care of it and keeping it 
cold. It is just as important to keep pasteurized milk oold as it is 
to keep raw milk cold, because pasteurization simple diminishes 
the number of microorganisms. It does not destroy them entirely. 

While it is easier to approach laboratory methods in the home 
than under commercial conditions, it is wiser to adopt 145° F. 
(62.7° C.) for thirty minutes as the standard instead of 140° F. 
(60° C.) for twenty minutes, in order to be sure that the pasteur- 
ization is efficient. The changes produced in the milk at this 
temperature and time are little, if any, greater than at the lower 
temperature and shorter time. 

It is not necessary to have any special apparatus for the pasteur- 

1 Schorer and Rosenau: Jour. Med. Res., 1912, xxvi, 127. 

2 Schorer: Am. Jour. Dis. Child., 1912, hi, 226. 



AND INFANT FEEDING 175 

ization of milk in the home, as any dish of sufficient size and depth 
will do. Each feeding should be placed in a separate, clean, boiled 
bottle. The bottle should then be tightly stoppered with non- 
absorbent cotton and placed in a pail or dish of cold water, the 
water in the dish being at the level of the milk in the bottle. The 
dish should then be placed on the stove and heated until the 
thermometer, suspended in the water, reaches 145° F. (62.7° C). 
The dish and its contents should then be taken off the stove and 
covered with a blanket. It should be allowed to stand for thirty 
minutes. The bottles should then be taken out, cooled quickly, 
preferably in running water, and kept in a cold place until used. 

There are several pasteurizers on the market, designed for home 
use, which are more convenient, although no more efficient. 
That sold by the Walker-Gordon Laboratory is a good one. An- 
other, designed by Dr. R. G. Freeman of New York, although 
working on a little different principle, is very satisfactory. 



176 DISEASES OF NUTRITION 



CHAPTER XVI 
CERTIFIED MILK 

Certified milk is the product of dairies operated in accordance 
with accepted rules and regulations formulated by authorized 
medical milk commissions to insure its purity and adaptability 
for infants and invalids. The methods and standards for the 
production and distribution of certified milk adopted by the Amer- 
ican Association of Medical Milk Commissions, May 1, 1912, are 
in brief as follows: 

The surroundings of all buildings shall be kept clean and free 
from accumulations of dirt of all sorts, and the stable yards shall be 
well drained. The pastures shall be free from marshes, stagnant 
pools or streams which may be contaminated. The buildings shall 
be so located as to afford proper shelter and drainage and relative 
freedom from dust. The stables shall be so constructed as to 
facilitate the prompt and easy removal of waste products. The 
floors shall be of non-absorbent material and the gutters of cement. 
All interior construction shall be smooth and tight. The drinking 
and feed troughs shall be cleaned daily. The stanchions shall be 
provided with throat latches. The stables must be provided with 
adequate ventilation, each cow having at least 600 cubic feet of air 
space, with 2 ft. square of window area for each 600 cubic feet of 
air space. Flies, vermin and other animals shall be excluded from 
the buildings. The bedding must be clean and dry. The soiled 
bedding and manure shall be removed at least twice daily. Manure 
shall not be even temporarily stored within 300 feet of the barn or 
dairy building. Cleaning of the barn shall be done at least an 
hour before milking time. The cows shall be groomed daily, and 
the hairs about the udder and tail clipped short. The udders and 
teats shall be cleaned, washed with a cloth and water and wiped 
dry with another clean sterilized cloth, before milking. Food- 
stuffs shall be brought into the barn only immediately before the 
feeding hour, which shall follow the milking. The food shall be 
suitable and well balanced. The cows must have at least two hours 
out of door exercise daily in suitable weather. The hands of the 
milkers shall be washed thoroughly and dried before beginning 
milking and before the milking of each cow. Clean outside clothes 



AND INFANT FEEDING 177 

and a cap shall be worn during milking, these to be washed or 
sterilized each day. The fore-milk shall be rejected. The milk of 
all cows shall be excluded for a period of forty-five days before 
and seven days after parturition. The milk shall be taken immedi- 
ately to a clean room and emptied through strainers of cheesecloth 
or absorbent cotton into a can. 

The dairy building shall be located at a suitable distance from 
the stable and dwelling and there shall be no hogpen, privy or 
manure pile at a higher level or within 300 feet of it. The dairy 
building shall be kept clean and shall not be used for purposes 
other than the handling and storing of milk and milk utensils. 
It shall be well lighted, screened and drained. 

The temperature of the milk shall be immediately reduced to 
45° F. and maintained at a temperature between 35° F. and 45° F. 
until delivery to the consumer. The bottles shall be properly 
sealed, the seal to include a sterile hood which completely covers 
the lip of the bottle. The bottles shall be properly cleaned and 
sterilized. The milk pails shall be properly made and preferably 
have an elliptical opening 5 by 7 inches in diameter. The water 
supply shall be free from contamination. Proper toilet facilities 
shall be provided for the milkers outside the stable and milk house. 

The milk packages must be kept free from dust and dirt during 
transportation. No bottles shall be collected from houses in which 
there is a communicable disease. All certified milk shall reach the 
consumer within thirty hours after milking. 

The herd shall be free from tuberculosis, as shown by the proper 
application of the tuberculin test by the veterinarian of the com- 
mission. The test shall be applied at least annually. All cows 
shall be properly registered. Cows sick with other diseases than 
tuberculosis shall be isolated and their milk destroyed until the 
cows are restored to the herd by the veterinarian. 

Certified milk shall contain less than 10,000 bacteria per cubic 
centimeter when delivered. Bacterial counts shall be made at 
least once a week. 

The fat standard for certified milk shall be 4%, with a permis- 
sible range of variation of from 3.5% to 4.5%. Higher fat per- 
centages for milk or cream may, however, be certified. The fat 
content shall be determined at least once a month. 

The protein standard shall be 3.50%, with a permissible range 
of variation of from 3% to 4%. The milk shall be free from adul- 
teration and coloring matter and preservatives shall not be added 
thereto. The milk shall not be subjected to heat unless especially 
directed by the commission to meet emergencies. The specific 



178 DISEASES OF NUTRITION 

gravity shall range from 1.029 to 1.034. It shall be determined 
at least once a month. 

No person shall be emploj^ed in the production or handling of 
milk until he has been found healthy by the attending physician. 
No person shall be employed who has been recently associated with 
children sick with contagious diseases. Suitable dormitories and 
bathing facilities shall be provided for the employees and they 
shall be required to use them. If a contagious disease develops 
among the employees, the employees shall be quarantined, the 
premises fumigated and the milk pasteurized as long as the com- 
mission thinks necessary. The commission shall have power to act 
as its judgment dictates when contagious diseases are present. 

It is possible to produce a reasonably clean milk without ful- 
filling all the requirements of the American Association of Medical 
Milk Commissions for the production of certified milk. It is 
possible to do this, moreover, without increasing materially the 
cost of the production of the milk. The milkers and those who 
handle the milk must, of course, be clean. So also must be the 
utensils which are used. The barns can easily be so arranged as to 
be reasonably free from dust and dirt. Experience has shown that 
the contamination of the milk is much less when the cows are milked 
out of doors than when they are milked indoors. If the cows are 
milked indoors certain precautions should be taken to avoid filling 
the air with dust. No dry feed should be given at or just before 
the time of the milking and the floors should not be scraped or 
cleaned just before milking. The cows should not be dry brushed 
before milking. The flanks and udders may be wiped instead of 
washed before the milking. This is nearly as effectual and much 
less expensive. A covered milk pail should always be used as it 
diminishes the contamination at least 50%. 



AND INFANT FEEDING 179 



CHAPTER XVII 
GENERAL PRINCIPLES OF ARTIFICIAL FEEDING 

In approaching the subject of artificial feeding it must be remem- 
bered that there are only a few food elements. A baby's food may 
contain all of these elements, it must contain some of them, it 
cannot contain any other elements. These food elements are fat, 
carbohydrates, protein and salts. The carbohydrates comprise 
the sugars and starches. 

It must also be remembered that a baby, in order to thrive and 
gain, must have a sufficient amount of food. The amount of food 
is not calculated, however, in ounces or pints of food, but in food 
values, or calories. A baby must receive a sufficient number of 
calories in proportion to its body weight. Otherwise, it cannot 
gain. It is not sufficient, however, for a food to contain a sufficient 
number of calories; it must also contain a sufficient amount of 
protein to cover the nitrogenous needs of the baby. A baby will 
eventually die while taking a food high in calories but too low in 
protein. 

It must further be remembered that a food may contain a 
sufficient number of calories and a sufficient amount of protein to 
cover the caloric and protein needs of the baby and yet not be a 
suitable food for any baby, or, if suitable for one baby, not for 
another. It is absolutely necessary to fit the food to the digestive 
capacity of the individual infant. Otherwise it will cause disturb- 
ance of the digestion and the baby will not thrive. 

These fundamental principles must always be borne in mind in 
feeding babies artificially. If a single one of them is forgotten, the 
results will be failure rather than success. 

It would seem at first glance as if an artificial food, which con- 
tained the same food elements in the same relative proportions 
that they are in human milk, would be a perfect food and answer 
as well as human milk. It has been shown, however, that, while 
some babies will thrive on a food of this composition, it is not 
suitable for all babies or for all ages. While babies thrive through- 
out the nursing period on human milk of uniform strength, they 
cannot take a food as strong as this in the early weeks and months, 
and need a stronger food in the latter months. It is a fact, more- 



180 DISEASES OF NUTRITION 

over, that no artificial food, although it may contain the same 
proportions of the different food elements, is the same as human 
milk. It is impossible, as will be shown later, to make an artificial 
food in any way which is identical with human milk. 

The composition of human milk does, however, teach us certain 
things as to the digestive capacity of infants and as to the general 
principles to be followed in the preparation of a food to meet this 
digestive capacity. Nature provides a dilute food rich in fat and 
carbohydrates and relatively low in protein, that is, rich in heat- 
producing substances and relatively low in tissue building sub- 
stances. It seems reasonable to suppose that this type of food is 
the one best suited for the infant's digestive power and metabolic 
processes. Well babies should, therefore, be given dilute foods 
which contain relatively large amounts of fat and carbohydrates 
and relatively small amounts of protein. The object in giving 
babies such foods is, however, not to imitate the composition of 
breast-milk but to follow Nature's indications as to the infant's 
digestive capacity and metabolic processes. Well babies, as 
already stated, on the whole thrive better on foods of this char- 
acter than on any others. The same principles cannot, however, 
be applied to the feeding of sick babies or to that of a certain 
number of well babies. When a baby does not thrive on foods of 
this type, they must be discarded at once and the composition of 
the food regulated to fit the digestive capacity of the individual 
baby. This digestive capacity must be determined by a careful 
study of the symptoms and of the stools in the individual case. 
The composition of the food must then be varied to suit the in- 
dividual baby. Success in the artificial feeding of infants can 
never be attained by following any hard and fast rules. Every 
baby is a problem by itself. The baby, not rules, must be followed 
to solve this problem. 

The artificial food for a baby is best prepared from the milk of 
some animal for the following reasons: The milk of animals con- 
tains the same food elements which are present in human milk. 
It does not contain any other elements. It is intended for the 
growth and development of a young animal. No other food has 
these same characteristics. It must be remembered, however, that 
the milk of an animal is fitted to the digestive capacity and in- 
tended for the growth and development of the young of that 
animal and not for the human infant. It is, therefore, not entirely 
suitable for a baby, and, while some babies will thrive on the un- 
diluted milk of an animal, in most instances it has to be modified 
in some way to be suitable for a baby. 



AND INFANT FEEDING 181 

The milk of the cow is the one most suitable for the preparation 
of a baby's food. The milk of the mare, it is true, resembles more 
closely in its composition that of human milk than does cow's milk. 
Its use as a food for babies is, however, not feasible, because of its 
rarity and the difficulty in obtaining it. The milk of the goat, 
which is claimed by some authorities to be better than cow's 
milk as a food for babies, resembles in its composition that of 
human milk a little more than does cow's milk. The difference is 
so slight, however, that goat's milk has to be modified to fit the 
digestion of the average baby in the same way as cow's milk. 
Cow's milk is easy to obtain in any amount, in almost any place. 
It is difficult to obtain goat's milk in large amounts, and then 
only in a few places. There is, therefore, no reason for preferring 
goat's milk to cow's milk. The reasons that goat's milk has been 
considered better than cow's milk for the feeding of infants are 
probably because goat's milk was given to the babies when it was 
fresh and cow's milk when it was old, and because in the countries 
where goat's milk was used most freely the cows were tubercular 
and the goats, on account of their resistance to infection with 
tuberculosis, were not. At the present time when so much is 
known about infant feeding, these reasons are not applicable. 
Pure milk can now be obtained by anyone who will take the 
trouble to get it, and anyone who does not take the trouble to 
find out whether the milk which is given to a baby comes from 
tuberculin tested cows or not, deserves to have tuberculosis develop 
in the babies. 

Idiosyncrasy to Cow's Milk. — It is often said that certain 
babies cannot take cow's milk in any form and that they must be 
fed, therefore, in some other way. In most of these cases the 
trouble is not with cow's milk but with the way in which it has 
been given. Almost all of these babies can take cow's milk per- 
fectly well if it is properly modified to fit their individual digestive 
capacities. In rare instances, however, cow's milk does cause 
serious disturbances in whatever form it is given, whether as 
cream, skimmed milk, whey or condensed milk. In such cases even 
a very small amount will cause trouble. In these instances the 
symptoms are probably manifestations of anaphylaxis to the 
protein of cow's milk. It will almost always be found that these 
babies were given cow's milk in the first few days of life at a time 
when the intestines were in an abnormal condition. The foreign 
protein of the cow's milk was probably absorbed at that time and 
produced the sensitization. Such babies have to be given either 
breast-milk or goat's milk until they are old enough to take other 



182 DISEASES OF NUTRITION 

foods than milk. The idiosyncrasy is usually outgrown during 
early childhood. 

Modified Milk. — The composition of human milk and cow's 
milk has already been given. They are roughly as follows : 

TABLE 38 

Human milk Cow's milk 

Fat 4.00% 4.00% 

Sugar 7.00% 4.75% 

Protein 1.50% 3.50% 

Salts 0.20% 0.70% 

Both are amphoteric in reaction when they leave the breast. 
Cow's milk is usually acid when it reaches the baby. Human 
milk is practically sterile as the baby takes it. Cow's milk, even 
under the best conditions, is far from sterile when the baby gets it. 
The emulsion of the fat is much finer in human milk than in cow's 
milk. The proportion of fatty acids is much higher in cow's milk 
than in human milk. A large proportion of the protein in human 
milk is in the form of whey protein. A large proportion of the 
protein in cow's milk is in the form of casein. Human milk is not 
coagulated by commercial rennin, cow's milk is coagulated. Both 
are coagulated by human rennin. The enzymes of the two milks 
are different and each milk has a specific serum reaction. 

It is evident, therefore, that no matter how cow's milk is mod- 
ified, it will still be different from human milk. The percentages 
of the different food elements can be made the same. The differ- 
ence in the protein can be corrected by the use of whey. The 
emulsion and the composition of the fat will, however, always be 
different. The ferments can never be made the same and the 
specific serum reaction cannot be changed. It is also evident that 
cow's milk must be modified in some way in order that the different 
food elements may be in the same relations in the food that they 
are in human milk. 

Pure Milk. — The milk from which a baby's food is prepared 
must be pure. It is impossible to make a proper food for a baby 
from impure and dirty -milk, no matter how much it is modified or 
how much care is taken in its preparation. The requisites of a 
pure milk have already been described. 

Breeds of Cows. — It also makes a difference from what breed 
of cows the milk comes. The milk of Ayreshires and Holsteins is 
much more suitable than that of Jerseys and Guernseys, because 
of the lesser fat content, the finer division of the fat and the lower 



AND INFANT FEEDING 183 

proportion of volatile fatty acids. The milk of the former breeds 
should, therefore, be always employed, if possible. Some babies 
can take Jersey milk without being disturbed, other babies cannot. 
It will be found in many instances that babies can take the same 
amount of fat in mixtures made from the milk of Holstein and 
Ayreshire cows without derangement of digestion while there is 
serious disturbance when the milk comes from Jerseys or Guern- 
seys. 

Mixed Milk versus the Milk of One Cow. — It is far better, other 
things being equal, to use the mixed milk of a herd in preparing a 
baby's food than the milk of one cow, because if the milk comes 
from one cow and the cow is ill in any way, the baby is almost 
certain to be disturbed, whereas if one or two cows in a herd are 
ill, the milk from these cows will be so diluted that the baby will 
probably not notice it. On the other hand, it is, or should be, 
self-evident that the milk of a healthy cow properly fed and 
properly cared for, taken in the proper way, and kept under proper 
conditions, is better than the mixed milk of a herd which is im- 
properly fed and whose milk is not carefully obtained or carefully 
taken care of. 

GENERAL PRINCIPLES OF THE MODIFICATION OF MILK 

It is evident, when the composition of human milk and cow's 
milk is compared, that, while the percentage of fat is the same in 
the two milks, the percentage of sugar is higher and that of the 
protein lower in human than in cow's milk. It is necessary, in 
order to have foods prepared from cow's milk correspond in the 
general relations of the fat, sugar and protein to each other to 
those in human milk and, therefore, to meet the indications for a 
food suitable for the average well baby, to modify these relations in 
some way. Simple dilution of cow's milk does not change these 
relations at all. Simple dilutions of whole milk do not, therefore, 
provide a suitable food for the average well baby. 

It is a fact that when milk stands the fat rises to the top, while 
the sugar and protein remain approximately evenly divided 
throughout the mixture. This fact of the unequal division of the 
fat and the comparatively equal division of the sugar and protein 
is also true when milk is separated by machinery. The cream 
contains a relatively large amount of fat and a relatively small 
amoimt of sugar and protein, when compared with whole milk. 

Cream is technically any milk which contains more than 4% of 
fat. The composition of different creams is as follows: 



184 


DISEASES OF NUTRITION 
TABLE 39 






Fat 


Sugar 


Protein 


10% cream 

16% " 


10% 

16% 
32% 


4.45% 

4.20% 
3.40% 


3.27% 
3.05% 


32% " 


2.50% 







It is evident that when cream is diluted the relation between the 
fat and the protein will be similar to that in human milk. For 
example, a mixture of one part of 16% cream with three parts of 
water will contain 4% of fat and about 0.75% of protein, while a 
mixture of one part of 10% cream with three parts of water will 
contain 2.50% of fat and approximately 0.80% of protein. It is 
very easy to raise the percentage of sugar, in order to get a rela- 
tively high sugar content, by the addition of dry milk sugar. The 
modification of cow's milk to fulfill the indications given by Nature 
as to the average infant's digestive capacity consists roughly, 
therefore, in the dilution of cream with water and the addition of 
dry milk sugar. 

If the modifications of milk prepared on these general principles 
do not fit the individual baby, it is easy to increase the percentage 
of protein in relation to the percentage of fat by the addition of 
skimmed or fat-free milk, which contain a considerable amount of 
protein and very little fat. If the casein is not easily digested, it is 
easy by the use of whey in the mixture to replace a part of it by 
whey protein. If it is desired to give a baby starch in its food, 
starch can be added in the form of a cereal water. If it is desired, 
for any reason, to change the character of the sugar, another sugar 
may be added in place of milk sugar. In these ways all possible 
modifications of cow's milk may be obtained and the needs of the 
individual baby met. 

FEEDING IN PERCENTAGES 



The most satisfactory way of determining the composition of an 
infant's food is by thinking and calculating in percentages of the 
different elements of the food. Percentage feeding, so-called, is not 
a method of feeding. It is merely a method of calculation and a 
means of attaining relative accuracy in the preparation of infants' 
foods. It neither presupposes nor implies anything as to what 
should be in the food or why it should be there. These points must 
be determined in other ways. Accuracy is as important in the 
calculation and writing of a prescription for a baby's food as in that 



AND INFANT FEEDING 185 

for a medicine. In no other way are such accurate results obtained 
as by the percentage method. It must not be supposed, however, 
that the mixtures, when prepared, contain exactly the percentages 
of the food elements which they are calculated to contain. This 
would be an impossibility, because the cream, milk and so on of 
which they are made are not constant in their composition. This 
is especially true when the mixtures are prepared at home. The 
percentages are, however, approximately correct and nearly enough 
so for practical purposes. Fortunately most babies do not notice 
slight variations in the composition of the food. In fact, the varia- 
tions in the composition of a mixture from day to day are probably 
less than the daily variations in the composition of a breast-milk. 
In any event, the relative proportions of the various food elements 
are correct, even if the exact percentages are not. If the food does 
not agree, changes in the percentages to meet the indications 
furnished by the symptoms will be accurate relatively to the 
original percentages, which is all that is necessary. 

USE OF CALOKIES IN INFANT FEEDING 

The calorie referred to in infant feeding is the large calorie, that 
is, the amount of heat necessary to raise one kilogram of water 
1° C. A baby cannot thrive and gain unless its food contains a 
sufficient number of calories in a form which can be utilized by the 
baby. In general, babies require from 100 to 120 calories per 
kilogram of body weight during the first six months in order to 
gain, and in the neighborhood of 100 calories during the rest of the 
first year. Ninety calories per kilogram is usually sufficient during 
the second year. Most young babies will just about hold their 
weight on 70 calories per kilogram, a few will gain regularly on this 
amount while other babies need as much as 140 calories per kilo- 
gram in order to gain. Babies that have been underfed or that are 
convalescing from a severe illness, whether acute or chronic, need 
more calories than do normal babies. Babies that are fatter than 
the average baby will gain on fewer calories than will the average 
baby. The fatter the baby is, the fewer calories he needs, a very fat 
baby often needing only 90 calories per kilogram. Conversely, the 
thinner or more atrophic a baby is, the more calories it needs, many 
extremely emaciated babies requiring as much as 160 calories per 
kilogram. Another factor which modifies the caloric need of an 
infant is its muscular activity. The quieter a baby is, the less 
food it requires, and vice versa. That is to say, there is no hard 
and fast rule as to how many calories a given baby must have in 



186 DISEASES OF NUTRITION 

order to gain. The calculation of the caloric value of the food 
will show whether the failure to gain is due to an insufficient 
amount of food or to some other cause. On the other hand, if a 
baby has a disturbance of the digestion on a food which seems 
suitable for it, the calculation of the caloric value of the food will 
show whether the disturbance is due to overfeeding or not. It must 
be remembered, however, that while the caloric value of a food 
may be high, the food may be valueless to the baby, because it 
cannot utilize it. Cheese and crackers both have a high caloric 
value, but they are not suitable articles of diet for a three months' 
old baby. A food the caloric value of which is high and the com- 
position of which is suitable for the average baby may in like 
manner be of but little value in a given case. For example, if a 
baby with an intolerance for fat is given a food whose caloric 
value is correct but which is due in considerable part to its fat 
content, it will not only not gain on this food but will be made ill. 
On the other hand, if the caloric value is due to the presence of 
sugar and protein, it would be able to utilize them and gain. 
Chapin has recently shown, moreover, that on account of the 
different powers of fat and carbohydrates as producers of meta- 
bolic water, they cannot be considered as interchangeable as 
regards favoring the growth of the organism. He has also called 
attention to the fact that the net caloric value of a food depends on 
the amount of energy required for its digestion and assimilation. 
Foods having the same gross caloric value may differ very mate- 
rially, therefore, in their net caloric value. 1 It has also been 
shown many times that the caloric needs of an individual, whether 
baby or adult, depend very largely on the amount of exertion 
which the individual makes, the need of food for the produc- 
tion of energy depending on exertion. It is evident, therefore, 
that a quiet baby which sleeps all day requires much less food 
energy than an active, restless baby, or one which cries most of 
the day. 

It is evidently irrational, therefore, to base any scheme or system 
of feeding on the caloric needs of babies or on the caloric values 
of food. The calculation of the calories in a given food can 
serve merely as a check. Used in this way it is often of great 
value. 

Intervals in Artificial Feeding. — While, as already stated, 
babies that are nursed do much better on the whole when they are 
fed at regular intervals, many of them get along fairly satisfac- 

1 Chapin: New York Medical Journal, 1913, xcvii, 269. 



AND INFANT FEEDING 187 

torily and some of them thrive perfectly well, even if fed at any 
and all times. This is not the case with artificially-fed babies. 
They are almost certain to be upset and suffer from disturbances of 
digestion, unless they are fed at regular intervals. Regularity is 
not only advisable with them, as with the breast-fed baby, but 
necessary. In general, the intervals are the same for the artificially 
fed as for the breast-fed. It is impossible and irrational, however, 
to lay down any arbitrary rules as to the intervals between feedings 
at different ages. They must vary with the amount of food given 
at a feeding, the strength of the food and its composition, as well as 
with the digestive capacity and gastric motility of the individual 
infant. It is evident that if a large amount is given at a feeding, 
the intervals between feedings must be longer than when a small 
amount is given, as the time required for the stomach to empty 
itself will be longer. The time required for the stomach to pass on 
a food rich in fat is greater than that required to pass on one poor in 
fat, because fat delays the emptying of the stomach. A mixture in 
which the protein is largely in the form of whey protein will leave 
the stomach more quickly than one in which the protein is almost 
entirely casein. Foods rich in carbohydrates and low in fat and 
protein leave the stomach quickly. There is no doubt that the 
digestive capacity and gastric motility is different in different 
infants. It is evident, therefore, that the intervals must be deter- 
mined in each case on the conditions actually present in that case, 
not by any set rules. 

Amount of Food at Single Feeding. — When a baby is nursed, 
Nature, under normal conditions, regulates the supply to the 
demand and there is no danger of overfeeding. There is no such 
natural relation, however, between what the person in charge of a 
baby may think it requires and its actual needs. A breast-fed 
baby, while it will take practically the same amount of milk from 
day to day, does not take the same amount at each feeding. It will, 
in fact, often take three or four times as much at one feeding as it 
does at the next without suffering any disturbance of the digestion. 
It has been found, however, that it is not safe to let a baby take all 
that he will at each feeding from an unlimited supply of artificial 
food. If this method is followed, indigestion almost invariably 
results. In order to avoid trouble, the baby must be given the 
same amount at each feeding. This amount is the maximum which 
is proper for the given baby. It is not necessary, however, that 
the baby always takes the whole of it. 

It is very difficult, indeed, to know just how much food a baby 
should take at a feeding. It depends not only on the age, but 



188 DISEASES OF NUTRITION 

also upon the size of the individual baby. Some babies, moreover, 
require more food than other babies of the same age and weight. 
The amount of food given at a feeding must depend also on the 
intervals between feedings. It is self-evident that, the twenty-four 
hour amount being the same, more food must be given at a feeding 
when the intervals are long than when they are short. The amount 
of food to be given in 24 hours is the most important point to be 
determined. When this is decided, it must be divided equally 
according to the number of feedings to be given. If the twenty- 
four hour amount is correct, the amount given at a feeding and the 
number of feedings are, within reasonable limits, relatively un- 
important. The figures as to the gastric capacity at different ages 
are of comparatively little value because of the difficulties and 
inaccuracies inherent to the various methods of determining them. 
Even if these figures were correct, they would not be of great value, 
because of the fact that more or less of the food ingested passes 
from the stomach into the duodenum while it is being taken. How 
much passes varies undoubtedly in different babies and in the same 
baby at different times. 

Experience has shown that the amount of food taken in twenty- 
four hours increases rapidly during the first three months and less 
rapidly during the remainder of the first year. The average baby 
takes ten or twelve ounces at the end of the first week, twenty 
ounces when a month old and thirty-two ounces when four months 
old. It will take thirty-six to forty ounces at six months and forty- 
eight ounces at nine months. 

It is evidently impossible, therefore, to give any absolute figures 
as to how much food should be given a baby of a certain age. In 
a general way, however, the average baby takes about one-half 
ounce at a feeding in the first few days, and an ounce to an ounce 
and a half when it is a week or ten days old. It takes about two 
and one-half ounces when it is a month old, four ounces at three 
months, six ounces at six months and eight ounces at nine months. 
It is, as already stated, impossible to lay down any hard and fast 
rules as to the intervals between feedings and the amount to be 
given at a single feeding at given ages. The intervals and the 
amount at each feeding must vary with the circumstances in the 
individual case. While this is true, it is, nevertheless, possible to 
give certain figures, founded on what average babies have been 
found by experience to have done in the past, as to what the 
average baby may be expected to do. These figures must not be 
followed blindly, but can serve as a guide as to what may be 
expected of an average baby of a given age. 



AND INFANT FEEDING 

TABLE 40 



189 



Age 



24-hour amount 



Number of feedings, amount and 
intervals 



1 week. 

4 weeks 

4 mos. . 
6 mos. . 
9 mos. . 



10-12 oz. 

20 oz. 

32 oz. 
36-40 oz. 

48 oz. 



10 feedings of 1 oz. at 2 hr. intervals 



l^oz. 2^hr. 

2Y 2 oz. 2}4 hr. 
3 oz. 3 hr. 

4H oz. 3 hr. 

6 or 63^ oz. 3 hr. 

8 oz. 3 hr. 
9^ oz. 3 or 4 hr. 



Ten feedings at two-hour intervals means every two hours from 
6 A. M. to 10 P. M. and once between ten and six at night. 

Eight feedings at two and one-half hour intervals means every 
two and one-half hours from 6 A. M. to 9 P. M. or 10 P. M., and 
once between the evening feeding and morning. 

Seven feedings at three-hour intervals means every three hours 
from 6 A. M. to 9 P. M. or 10 P. M., and once between ten and six 
at night. 

Six feedings at three-hour intervals means every three hours 
from 6 A. M. to 9 or 10 P. M. 

Five feedings at three-hour intervals means every three hours 
from 6 A. M. to 9 P. M. 

Five feedings at four-hour intervals means every four hours from 
6 A.M. to 10 P.M. 

The night feeding may be omitted, in many instances, before the 
baby is six months old. If so, the amount which was in this 
bottle must be distributed among the other bottles in order to keep 
the twenty-four hour amount the same. 

Composition of Food at Different Ages. — It is impossible to 
over-emphasize the facts that babies cannot be fed by rule and 
that the food of each baby must be adapted to the digestive 
capacity of that individual baby. It is equally true, however, that 
young infants cannot take as strong an artificial food as older 
babies and that the average well baby thrives better on artificial 
foods in which the relation of the fat, sugar and protein in the 
mixture are similar to those in human milk. Experience in the 
feeding of large numbers of well babies has shown that, on the 
average, babies of certain ages take, digest and thrive best on 
certain strengths of food. The expert in the feeding of infants has 



190 



DISEASES OF NUTRITION 



no need of tables showing the average strength of food taken at 
different ages. He is able to judge very closely from the age, 
appearance and past history of the baby what food is suitable for it. 
Those of less experience, however, need such a table to serve as a 
guide in the preparation of the first mixture for a well baby when 
it comes into their hands, and to show them in a general way what 
the average well baby may be expected to take. In any hands, the 
first formula must always be something of an experiment. After 
this, the food must be prepared to meet the indications furnished 
by the symptoms, the findings in the stools, the appearance and the 
weight chart of the individual baby at the given time. 

TABLE 41 
Composition of Food for Average Well Babies 



Age 


Fat 


Sugar 


Protein 


First food 


1.00 
2.00 
3.00 
3.50 
4.00 
4.00 
4.00 


5.00 
6.00 
7.00 
7.00 
7.00 
7.00 
7.00 


0.50 


First week 

1 month 


0.75 
1.00 


2 months 


1.50 


4 months 


1.75 


6 months 


2.25 


8 months 


2.50 







Variation of Different Food Elements. — It is possible not 
only to vary the percentages of the different elements in the food, 
but also to use these elements in different forms. There are, for 
example, several varieties of sugar, one of which will agree in one 
condition, another in another. Barley starch may be used in one 
instance, oat starch in • another. Whey protein may be given 
instead of casein when the latter causes disturbance, or the casein 
may be partially digested by pancreatization. Alkalies may be 
added to the food or lactic acid organisms may be grown in it, and 
so on. 

Fat. — The amount of fat in the food may be varied, but the 
character of the fat cannot be changed, except in so far as it differs 
in the milk of different breeds of cows. The emulsion of the fat 
may be made much more complete, however, by means of the 
process known as "homogenization," by which the fat droplets 
are rendered extremely small. Other fats, such as olive oil, may 
also be introduced into the milk by this process. It has been 
thought by some physicians that the cream obtained by centrifu- 
galization is less suitable for the preparation of foods for infants 



AND INFANT FEEDING 191 

than that obtained by gravity. There is, however, no proof that 
this is so, and the general experience is that it makes no difference 
whether the cream is obtained by gravity or centrifugalization. 
The upper layers of cream which has risen contain many more 
bacteria than the lower. It is of certain advantage, therefore, to 
remove the upper two ounces of cream from each quart in order to 
reduce the bacterial contamination. 1 

Very few babies are able to take more than 4% of fat in their 
food continuously without developing disturbances of digestion or 
of nutrition. More than 4% of fat should, therefore, never be 
given, except for special indications, and, if it is so given, it should 
not be kept up for any length of time. Most well babies over three 
months old can take 4% of fat without any trouble resulting. 
Indeed, in most instances they thrive better on this amount than 
on lower percentages. This is not the case with sick babies, how- 
ever, and here, as always, it must never be forgotten that con- 
clusions as to what is a suitable food for a sick baby cannot be 
drawn from what is suitable for a well one. It is safer when babies 
are fed on modifications of milk prepared at home not to give more 
than 3 H%, or even more than 3% of fat, because, as in most 
methods of calculation the fat content of the skimmed milk is 
disregarded, the foods always contain more fat than they are 
supposed to. 

One of the reasons why too high percentages of fat are given is 
the desire to make the baby gain in weight. Mothers are always 
and physicians not infrequently inclined to attach too much 
importance to the weight chart and, believing that fat tends to 
increase the weight more than anything else, to increase it unduly 
on this account. As a matter of fact, the fat baby is often not as 
strong and vigorous as the thinner baby, and fat in the food is no 
more useful than carbohydrates in increasing weight. 

Another reason why babies are given excessive amounts of fat is 
that most mothers and nurses, and unfortunately many physicians, 
think that fat always has a laxative action. They, therefore, in- 
crease the amount of fat in the food whenever a baby is con- 
stipated, not realizing that an excessive amount of fat is one of 
the most common causes of constipation in infancy. Increasing 
the percentage of fat in the food in such cases, of course, merely 
makes a bad matter worse. 

The chief reason why babies get excessive amounts of fat in their 
food is that physicians do not appreciate the fact that cream and 
top milk are indefinite terms or that, if they do appreciate this fact 
1 Hess: Journal A. M. A. 1909, liii, 523. 



192 DISEASES OF NUTRITION 

and are careful in their calculations, they are not precise enough in 
their directions as to the preparation of the food. If 32% cream is 
used in the preparation of a milk mixture, the formula for which 
was calculated on the basis of 16% cream, it is evident that the 
mixture will contain twice as much fat as was intended. In the 
same way, if a top milk mixture is made with a certain number of 
ounces from the top eight ounces instead of with the same number 
of ounces from the top sixteen ounces as ordered, it will contain 
nearly twice as much fat as it should, the fat content of the top 
eight ounces being 13.3% and that of the top sixteen ounces, 7%. 
The physician must always decide what percentage cream or what 
top milk he will use in the preparation of his mixture, and then 
calculate the amount to be used on the basis of its fat content. 
Otherwise, the fat content of the food will never be what he thinks 
it is. He must also give the person who is to prepare the food such 
explicit directions as to how to obtain the cream or top milk that 
they cannot possibly make a mistake. 

It must be remembered on the other hand, however, that the 
caloric value of fat is more than twice as great as that of the 
carbohydrates and protein. Unless a reasonable amount of fat is 
used in the food, it is, therefore, often difficult to meet the caloric 
needs without unduly increasing the quantity of the food. 

Sugars. — Milk sugar being the only form of sugar present 
in human milk and in the milk of animals, it seems reasonable to 
suppose that it is the sugar most suitable for the growth of the 
young organism, whether human or animal. It is hardly necessary, 
however, to adduce this argument in favor of milk sugar, because 
there are several reasons which show that it is the most suitable 
form of sugar for well infants. It is more slowly but more com- 
pletely absorbed than the other disaccharides. Being more slowly 
absorbed, it is present for a longer time and at lower levels of the 
intestines than the others, and is thus more conducive to the 
development and persistence of the normal fermentative flora 
throughout the intestinal tract. Few organisms, moreover, other 
than those normal to the intestinal tract of infants, utilize lactose 
before it is broken down, while many can utilize the other double 
sugars. It affords, therefore, a more efficient protection against 
abnormal bacterial processes in the intestine. 

It is probably true that the net energy value of milk sugar is less 
than that of malt sugar, because of the greater energy presumably 
required for its utilization. It does not seem probable, however, 
that this difference is sufficient to be of practical importance. It 
has been suggested that on account of the differences in the salts of 






AND INFANT FEEDING 193 

human and cow's milk, the sugar in the two milks may not be 
utilized in the same way. There is, however, no proof of the 
correctness of this suggestion. It has also been claimed that the 
lactose of cow's milk is not identical with that of human milk. 
There is, however, no convincing evidence in favor of this claim. 
No difference having thus far been found in the chemical composi- 
tion of lactose from different sources, it seems more reasonable, 
therefore, to consider them identical until they are proved not to 
be. It must be remembered, however, that commercial milk sugar 
is not always pure. 

No more than 7% of milk sugar should be given in an infant's 
food. If for any reason a larger amount of sugar than this is re- 
quired, the additional sugar should be given in the form of one of 
the combinations of dextrin and maltose. These sugars are quickly 
absorbed and the intestine is, therefore, not flooded with an excess 
of sugar for a long time, as it would be if milk sugar was used 
exclusively. Milk sugar is never found in the urine or feces under 
normal conditions, unless more than 7% of sugar is given. In fact, 
the assimilation limit of milk sugar, although lower than that of the 
other disaccharides, is far in excess of the amount which would be 
contained in any reasonable food. 

Lactose in reasonable amounts under normal conditions has a 
slight laxative action, as does maltose, while saccharose is slightly 
constipating. When given in excess, lactose is more likely than 
the other disaccharides to cause diarrhea, the order being lactose, 
saccharose, maltose and dextrin-maltose mixtures. The probable 
explanation of the greater frequency with which lactose causes 
diarrhea is its relatively slow absorbability. 

It is stated that lactose causes fever more readily than the other 
disaccharides, the order being lactose, saccharose and maltose. 
The fever is always accompanied by diarrhea, however, so that the 
presence of fever is no argument against the use of lactose in 
reasonable amounts under normal conditions. Schlutz's experi- 
ments render it very improbable, moreover, that, even when there 
is a rise in temperature, it is due primarily to the sugar. This so- 
called "sugar fever," provided there is such a thing, is, therefore, 
no argument against the reasonable use of milk sugar. 

When the disaccharides are added to a food which contains little 
or no sugar, there is a rapid increase in weight owing to the lessened 
elimination of water by the kidneys as the result of the presence in 
the organism of the products of assimilation of the sugar absorbed. 
The difference in the increase of weight with different sugars is 
due to the difference in the quantity of liquid eliminated by the 



194 



DISEASES OF NUTRITION 



kidneys. The gain in weight is more rapid with maltose and sac- 
charose than with lactose, probably because of the easier assimila- 
tion and more rapid absorption of these sugars. 1 This fact is the 
probable explanation of the sudden increase in weight which not 
infrequently follows the change from a modified milk prepared with 
milk sugar to one of the proprietary foods containing some com- 
pound of the dextrins and maltose. 

There can be no doubt, therefore, that under normal conditions 
the preferable sugar for the well infant is lactose. This is not the 
case, however, in many of the disturbances of digestion. Some of 
these are due to an excessive amount of milk sugar in the food. 
They can be quickly relieved by a reduction in the percentage of 
milk sugar. In others, while the disturbance is not due primarily 
to the amount of milk sugar, the chief cause of the symptoms is the 
fermentation of the milk sugar as the result of abnormal bacterial 
activity. In such instances the milk sugar must be stopped and 
some other form of sugar substituted for it. 

Maltose. — Pure maltose is never employed in the feeding of 
infants, being altogether too expensive to be used in this way. 
The various preparations to which this term is erroneously applied 
are mixtures of the various dextrins and maltose. The relative 
proportions of the dextrins and maltose are different in all of them. 
The relations of the various dextrins to each other are also different. 
The composition of a few of these preparations is as follows: 

TABLE 42 



Food 


Maltose per cent. 


Dextrin per cent. 


Soxhlet's Nahrzucker 


52.44 

40.00 

51.00 

63.00-66.00 

58.91 

57.10 

58.88 

49.15 2 


41.26 


Loflund's Nahrmaltose 

Mead's Dextri-Maltose 


60.00 
47.00 


Neutral Maltose (Maltzyme Co.) 


8.00-9.00 


Lonund's Malt-Soup Extract 


15.42 


Maltose (Walker-Gordon Laboratory) .... 
Mellin's Food 


30.90 
20.69 


Malted Milk 


18.80 







The properties of maltose and the dextrins are materially differ- 
ent. Maltose is a disaccharide, dextrins are polysaccharides. 
Maltose is a crystalloid, fermentable and dialyzable; the dextrins 
are reversible, protective colloids, non-fermentable and non- 
dialyzable. It is evident, then, that it is not a matter of little 

1 Borrino: Abstract in Archives of Pediatrics, 1911, xxviii, 869. 

2 A small proportion of the sugar is lactose. 



AND INFANT FEEDING 195 

importance which of these preparations is used. All are, of course, 
eventually absorbed in the form of dextrose. The dextrins, being 
protective colloids, in all probability have a favorable influence on 
the digestibility of the protein in the same way as does starch. 
Maltose has no such action. The dextrins have to be changed to 
maltose and then to dextrose before they are absorbed. The 
larger the proportion of dextrin in the dextrin-maltose mixtures, 
the slower, therefore, is the absorption of sugar and vice versa. 
There is, consequently, less danger of overtaxing the absorptive 
mechanism of the intestine and of flooding the organism with 
sugar when the proportion of the dextrins is relatively high. On 
the other hand, if it is desired to give the sugar in a form which 
can be very readily and rapidly absorbed, the proportion of maltose 
should be large. The preparations containing relatively large 
amounts of maltose are more laxative than those containing 
relatively large amounts of the dextrins, because of the larger 
amount of sugar which is present at one time in the intestine. 

When the dextrin-maltose preparations are prepared in the home 
by the action of enzymes on starch solutions the character of the 
product may be varied to a certain extent. Temperatures below 
131° F. (55° C.) produce the largest amount of maltose, and above 
145° F. (63° C.) produce the dextrins in excess. A temperature of 
167° F. (75° C), however, stops the action of the enyzmes. Pure 
maltose is never produced, because after the concentration of the 
maltose reaches a certain point, the further production of dextrin, 
and therefore of maltose, is inhibited. 

Maltose is split into dextrose and dextrose which can be imme- 
diately utilized. Lactose is split into dextrose and galactose, and 
saccharose into dextrose and levulose. Only the dextrose half of 
these sugars is, therefore, immediately available without further 
change. This immediate availability of the whole of the malt 
sugar is presumably of some advantage in feeble, emaciated babies, 
who have little or no reserve of glycogen in the liver, in that all the 
energy derived from the sugar may be used immediately in the 
digestion of the rest of the food, whereas the energy of the other 
sugars is not at once utilizable, the galactose and levulose halves 
having to be converted into glycogen in the liver and then recon- 
verted into maltose and dextrose. The net energy value of malt 
sugar is also presumably somewhat greater than that of lactose and 
saccharose, because the sugar being converted at once into dextrose, 
no further energy is required, as there is to convert the galactose 
and levulose. The immediate utilizability of malt sugar is the 
chief point in favor of the employment of this form of sugar in the 



196 DISEASES OF NUTRITION 

feeding of babies not suffering from disturbances of the digestion. 
This fact, while of importance in the feeding of feeble and ema- 
ciated babies who have but little or no reserve of glycogen in the 
liver, is of no advantage in the feeding of normal infants. In fact, 
it is probably somewhat of a disadvantage. Milk sugar, which is 
more slowly broken up and more slowly stored in the liver in the 
form of glycogen, is more suitable, in that it is less likely to overtax 
the liver and cause alimentary glycosuria and excessive fat produc- 
tion. 

Maltose, being more quickly absorbed, is less favorable to the 
maintenance of the normal fecal flora than lactose. Maltose, 
moreover, is especially conducive to the growth of the bacillus 
acidophilus, which, although normally present in small numbers, if 
present in large numbers is liable to produce an excessive degree of 
acidity, and this may cause irritation of the intestine and an intol- 
erance for sugar. Under normal conditions, therefore, as far as 
the maintenance of the normal intestinal flora is concerned, lactose 
is preferable to maltose. 

There is a form of indigestion, chiefly intestinal, in infancy due 
to the fermentation of milk sugar. In the convalescent stage of 
this condition the dextrin-maltose preparations can be given sooner 
than lactose without causing a return of the symptoms. Their use 
is, therefore, indicated in this condition. The preparations con- 
taining a relatively large proportion of dextrins are preferable, 
because they are broken down more slowly. Sugars are con- 
traindicated in diseases of the intestinal tract due to the gas 
bacillus and similar organisms. Maltose is more harmful than 
lactose because it undergoes butyric acid fermentation more 
readily. Maltose is less suitable than lactose for the feeding of 
infants ill with diseases due to the bacteria which produce toxic sub- 
stances from protein, and non-toxic substances from carbohydrates 
for several reasons. Lactose is more slowly broken down and 
absorbed and consequently exerts a more prolonged action. In 
the next place, few organisms except those normal to the intestinal 
tract of infants can utilize it before it is broken down by hydrolysis. 
There is also danger, as already pointed out, if maltose is given 
freely, of encouraging the overdevelopment of the bacillus aci- 
dophilus and developing a sugar intolerance. 

Cane Sugar. — There seems to be no evident reason for using 
cane sugar in place of milk sugar in feeding normal infants except 
that it is less expensive. It is true that many infants thrive on it. 
This fact, however, does not prove that it is preferable to milk 
sugar, because the average normal infant is able to utilize lactose, 



AND INFANT FEEDING 197 

saccharose or the dextrin-maltose mixtures indiscriminately, pro- 
vided they are not given in excess. That is, normal babies that 
thrive on cane sugar do so in spite of it, not because of it. Cane 
sugar, undergoing as it does alcoholic fermentation instead of 
lactic acid fermentation, is less suitable for the development and 
maintenance of the normal intestinal flora than milk sugar. Grant- 
ing that the experimental evidence that the assimilation limits of 
cane sugar are greater than those of milk sugar and that it is less 
likely to cause diarrhea and "sugar fever" than milk sugar is 
correct, which is certainly open to question, even then it is inferior 
in all these respects to the dextrin-maltose mixtures. Therefore, if 
there is any reason to believe that there is a disturbance of the 
digestion from the presence of milk sugar in the food, the dextrin- 
maltose mixtures should be substituted for the milk sugar, not 
cane sugar. The dextrin-maltose mixtures are also preferable to 
cane sugar in the feeding of feeble, emaciated infants to whom it is 
desirable to give a rapidly utilizable sugar because, like milk sugar, 
it is only half dextrose, the levulose being available only after 
further changes. 

It is stated that, when used continuously, cane sugar has a 
slightly constipating action, while milk sugar and the dextrin- 
maltose mixtures are slightly laxative. This action is, however, 
hardly strong enough to be of any practical importance. 

Starch. — It has been proved beyond question that amylolytic 
ferments are present in the saliva and pancreatic secretions of the 
new-born infant, even if it is born prematurely. These ferments 
are present and active in the breast-fed as well as in the artificially- 
fed infant. The amylase of the pancreatic secretion is more 
abundant after the first month than earlier. After the first month 
the activity of the pancreatic amylase seems to depend more on 
individual peculiarities than on the age of the baby. The amount 
of the secretion is apparently independent of the character of the 
food. It is not diminished in atrophic conditions. There are, 
therefore, no physiological contraindications to the use of starch in 
the feeding of infants, even of the new-born. This fact does not 
prove, however, that infants ought always to be given starch or 
that they should be fed on foods composed largely or almost ex- 
clusively of starch. It merely shows that there is no reason why 
starch should not be given to babies, if there is any good reason for 
using it. Clinical experience shows that, in general, it is not 
advisable to give starch to babies under two months old, although 
there are many exceptions to this general rule. Clinical experience 
also shows that it is inadvisable to give large amounts of starch to 



198 DISEASES OF NUTRITION 

babies before they are ten months old. It shows, on the other hand, 
however, that many babies do far better on foods containing starch 
than they do on foods which do not contain it. Starch should be 
used in the food of infants in the same way as the sugars, fat and 
protein, that is, intelligently and for definite purposes and indica- 
tions. The percentage of starch in the food should be just as 
carefully calculated as that of any of the other elements. 

The caloric value of starch is, for practical purposes, the same as 
that of sugar, the loss of nutritive value resulting from the greater 
energy expended in breaking down the starch being, for every-day 
work, negligible. The starch is, of course, ultimately converted 
into dextrose before it is utilized. Starch is used less frequently, 
however, primarily for its nutritive value than for its other prop- 
erties. 

Starch acts as a protective colloid and in this way prevents the 
formation of large casein curds. This action is due to the soluble 
starch itself, not to the salts or to cellulose in suspension. It has 
been found that percentages of starch greater than 0.75% in milk 
mixtures have no more effect in diminishing the size of the curds 
than does 0.75%, while smaller percentages have less effect. When 
starch is added simply for its effect on the coagulation of casein, 
0.75% is, therefore, the optimum amount. 1 This amount of 
starch is very seldom outside of the limit of tolerance of even the 
youngest and feeblest infant. 

Starch is very useful when it is desirable to give carbohydrates 
to infants in whom the sugars cause fermentation or in whom the 
tolerance for sugars is so low that they cannot be given in sufficient 
quantities to supply the caloric needs which cannot be met by fat 
and protein. The probable reason that babies can take car- 
bohydrate in the form of starch, when they cannot take it in the 
form of dextrins and sugar, is that the molecular structure of 
starch is more complicated than that of the dextrins and sugars. 
The more complicated the structure of a carbohydrate is, the more 
numerous are the steps in its breaking down to its end products. 
There are, therefore, less fermentable materials in the intestine at 
one time and less opportunity is afforded for fermentation to get 
the upper hand. 

Starch is used in infant feeding in the form of the cereal waters or 
gruels. The nutritive value of these waters and gruels rests almost 
entirely in the starch which they contain. The cereal waters 
contain about 1.50% of starch, 0.20% of protein and from 0.01% to 
0.05% of fat, The gruels contain about twice as much of each 
1 White: Journal of Boston Society of Medical Sciences, 1900, v, 125. 



AND INFANT FEEDING 199 

element. 1 When it is remembered that these cereal preparations 
are used merely as diluents it is evident that the food value fur- 
nished by the fat in them is essentially nil, and that furnished 
by the protein negligible. Cereal diluents made from the whole 
grains contain more protein, however, than those made from the 
corresponding flours. 

Starch is most commonly used in the form of barley or oat flour. 
Barley flour is usually considered to be somewhat constipating and 
oat flour to have a slightly laxative action. The action of these 
flours on the intestinal peristalsis is, however, not at all a constant 
one, barley starch having a laxative and oat starch a constipating 
action in some infants. Other forms of starch have been used but 
little in this country and it has been rather taken for granted that 
it makes but little difference what form of starch is used. This is 
probably true in most instances and when small amounts only are 
used. The investigations of Nagao 2 and Klotz, 3 show that barley 
and oat starch are broken down more rapidly by enzymes and bac- 
teria than are wheat and rye starch. The former flours are more 
likely, therefore, to cause acidity and fermentation than the latter. 

It must not be forgotten, however, that, while starch in reason- 
able amounts is often most useful in feeding infants, it may, if 
given in excessive amounts, cause very marked disturbances of 
digestion and of nutrition. The fermentation of starch results in 
the formation of free fatty acids, which exert a strong irritant 
action on the intestines and cause increased peristalsis. The 
injurious effect of these acids is the same, whether they are derived 
from carbohydrates or fat. 4 

On the other hand, an excessive amount of starch not infre- 
quently causes constipation. The stools in such cases are hard, 
dry and light-brown, resembling the soap stool except in their color. 

A baby on a purely carbohydrate diet or on one in which the 
carbohydrates are greatly in excess receives much less salts than it 
should, such a diet being poor in salts. The consequent disturb- 
ance in the retention of salts and water results in impairment of 
the nutrition and in marked diminution in the resistance to infec- 
tion. 5 Serious disturbances of nutrition from the excessive use 
of starchy foods, although apparently common abroad, are fortu- 
nately comparatively rare in this country. 

1 Ladd: Archives of Pediatrics, 1908, xxv, 256. 

2 Zeitschr. f. experiment. Path. u. Therapie, 1911, ix, 227. 
3 Archiv. f. experiment. Path. u. Pharmacol., 1912, lxvii, 451. 

4 Stolte: Jahrb. f. Kinderheilkunde., 1911, lxxiv, 367. 

5 Salge: Jahrb. f. Kinderheilkunde., 1912, lxxvi, 125. 



200 DISEASES OF NUTRITION 

Polycarbohydrates. — Attention has recently been called to the 
use of " poly carbohydrates " in infant feeding. Those who use 
this term mean by it a combination of several carbohydrates in the 
same food. They believe that, on account of the difference in the 
rapidity of absorption of the different carbohydrates, more car- 
bohydrate can be given in this way without overtaxing the power 
of the organism to assimilate and utilize sugar than when a single 
carbohydrate is used. This belief is unquestionably correct and 
there is no doubt that when there is a disturbance in the digestion 
of sugar it is of great advantage to give some of the carbohydrate 
in the form of starch. The rationale of the use of the dextrin- 
maltose mixtures and starch has already been considered in dis- 
cussing these substances. Those who advocate the use of " poly- 
carbohydrates " in infant feeding seem to forget, however, that 
mixtures of milk and cereal waters contain two carbohydrates, 
milk sugar and starch, and mixtures of milk, dextrin-maltose mix- 
tures and cereal waters four carbohydrates, milk sugar, malt sugar, 
dextrins and starch. The principle is, therefore, not a new one. 
Owing to the inferiority of cane sugar to the other sugars as a food 
for infants and the comparatively slight difference in the fer- 
mentability of the various forms of starch, it hardly seems neces- 
sary to complicate the mixtures further by the addition of cane 
sugar and by the use of several varieties of starch in the same food. 
The mixtures of milk, dextrin-maltose mixtures and simple cereal 
waters contain the carbohydrates in sufficient variety to meet the 
indications for the " polycarbohydrates." The malt sugar is 
absorbed first, then the milk sugar, next the dextrins and finally 
the starch. The absorption is thus comparatively slow and con- 
tinues for a long time. The sudden flooding of the organism with 
sugar is thus avoided. 

Protein. — While the fats and carbohydrates can, with certain 
restrictions which have been considered elsewhere, be used inter- 
changeably in feeding babies, neither can take the place of protein. 
The protein is essential to life, in that it is the only form of food 
which can replace the nitrogenous waste of the body and from 
which new cells can be built up. It is indispensable for the repair 
and growth of the body. New tissue cannot be formed from 
carbohydrates and fat. They serve as sources of energy. Protein 
can also serve as a source of energy and life can be sustained for 
considerable periods of time on a purely protein diet. Such a diet 
is, however, a wasteful one, throws an excessive amount of work 
on the organs of digestion and metabolism and seriously overtaxes 
the organs of elimination. 



AND INFANT FEEDING 201 

The protein need of the infant is much greater than that of the 
adult, in that it not only requires protein to replace tissue waste but 
also to build up new tissues. If the protein content of its food is 
below a certain level, it will eventually die of malnutrition, no 
matter how high the caloric value of the food. If the protein 
content is just high enough to cover the tissue waste and a little 
more, the baby will live, but it will not thrive properly. It may 
become fat, but it cannot form bone and muscle as it should. The 
cause of anemia, obscure disturbances of nutrition, delay in mus- 
cular development and various functional derangements of the 
nervous system in infancy is not infrequently a deficiency of protein 
in the food. The average protein need of infants is at least 1.5 
grammes per kilogram, or 0.7 grammes per pound of body weight. 
In all probability, many babies require as much as 2 grammes per 
kilogram, or 0.9 grammes per pound of body weight. Unless a 
baby gets this amount of protein in its food, it cannot thrive. It 
can often take much more than this with advantage. 

The most available and the most easily digestible form of pro- 
tein for infants is the protein of milk. The protein of woman's milk 
is more digestible than that of cow's milk. A part of the protein 
may be given in the form of vegetable protein, but vegetable pro- 
tein cannot permanently replace animal protein in the infant's 
food. 

There is no doubt that the opinion held some years ago that the 
protein was the most indigestible portion of cow's milk for infants 
and that the disturbances of digestion occurring in infants fed on 
cow's milk were almost entirely due to the protein, was an erro- 
neous one. It is probable, on the other hand, that at the present 
time the tendency is to minimize the possible power of protein to 
cause disturbances of digestion and metabolism and to attach too 
little importance to it. One cause for this tendency is presumably 
that the disturbances caused by the proteins are, like those caused 
by the salts, less easily recognizable than those caused by the 
carbohydrates and fats. It has recently been shown, for example, 
than an excessively high protein diet will cause fever. 1 The 
products of protein metabolism, when in excess, undoubtedly 
irritate the kidneys. Further undesirable results of an excessive 
amount of protein will, in all probability, be discovered as the 
subject is more carefully studied. 

The relation of the casein to the whey protein in human milk is 
approximately as 1 is to 2, while the relation in cow's milk is as 
3 to 1. While it is possible, and perhaps probable, that there are 

1 Holt and Levene: American Journal of Diseases of Children, 1912, iv, 265. 



202 DISEASES OF NUTRITION 

considerable chemical differences between the protein of human 
milk and that of cow's milk, this is not proved. Setting aside, how- 
ever, the undoubtedly important but still problematical action 
of the salts of the two milks on the digestibility of the protein, in 
the light of our present knowledge, the chief cause of the difference 
in the digestibility of the protein of human milk and that of cow's 
milk lies in the greater proportion of casein in cow's milk. In the 
first place, the absolutely greater amount of casein in cow's milk 
favors the formation of large, tough, casein curds, while the rela- 
tively smaller proportion of the whey protein to casein diminishes 
its collodial action in the prevention of the coagulation of the 
casein. 

It is the formation of large curds which renders the casein of 
cow's milk so much more difficult of digestion by the infant than 
that of human milk. If the formation of large casein curds in the 
stomach can be prevented, the casein of cow's milk is easily di- 
gested. Fortunately, the average normal infant can digest con- 
siderable amounts of cow's milk casein in the usual dilutions with- 
out anything being done to prevent the formation of large casein 
curds. It is of a certain disadvantage, moreover, to render the 
digestion of the casein too easy, because, if this is done, the develop- 
ment of the digestive powers is not encouraged as it should be. 

Methods of Preventing the Formation of Casein Curds. Re- 
duction of the Amount of Casein. — The simplest method of pre- 
venting the formation of casein curds is by diminishing the amount 
of the casein and thus giving it more diluted. In using this method, 
however, great care must be exercised not to reduce the casein 
so much that the protein need is not covered. Some other method 
is, therefore, usually preferable. 

Whey Mixtures. — One of the best methods of giving the pro- 
tein in an easily digestible form is the whey mixture. The whey 
protein is not coagulable by rennin and, therefore, cannot form 
curds. Moreover, by its colloidal action it hinders the formation 
of large, casein curds. The presence of the protein in the whey 
makes it possible to dimmish the casein materially without in- 
curring the danger of protein starvation which is always present 
when the casein is reduced by simple dilution. The whey mixture 
is less valuable when the food is prepared at home than when it is 
prepared at a milk laboratory, because, when gravhy cream is used, 
as it has to be in the home, the amount of cream which has to be 
used in order to have sufficient fat in the mixture carries with it a 
considerable percentage of casein and consequently reduces the 
amount of protein which can be given in the whey. When whey 



AND INFANT FEEDING 203 

mixtures are prepared at a milk laboratory, however, where high 
percentage creams can be used, the casein can be made very low 
and the whey protein high. 

Whey mixtures are also very useful when there is much vomiting, 
the whey protein, not being acted on by rennin, leaving the 
stomach very rapidly. 

Cereal Diluents. — Another method of hindering the forma- 
tion of large, casein curds is by the addition of cereal diluents, 
such as barley water, to the food. The soluble starch in these 
cereal diluents acts as a protective colloid. The salts and the 
suspended cellulose probably play no part in the action of these 
diluents. It has been found that percentages of starch greater 
than 0.75 in milk mixtures have no more effect in diminishing the 
size of the curds than does 0.75%, while smaller percentages are 
less effective. When a cereal diluent is added to an infant's food 
for the purpose of preventing the formation of large, casein curds, 
it should, therefore, be added in such a way that the starch con- 
tent of the mixture is 0.75%. 

Boiling. — One of the most effective, as well as one of the sim- 
plest, methods of preventing the formation of large, casein curds 
is the boiling of the food. When rennin is added in vitro to raw 
milk and the mixture kept at the proper temperature, a dense, 
hard coagulum, which separates completely from the whey, is 
quickly formed. When rennin is added to boiled milk, however, 
coagulation takes place more slowly, and the curd which is formed 
is soft and fine. The separation of the curd and whey is also 
much less complete than in raw milk, so that the appearance of the 
liquid is that of a thick homogeneous fluid. The experiments of 
Brennermann 1 and others show that the same differences in the 
coagulation of the casein of raw and boiled milk by rennin exist 
in the stomach as in vitro. The food must be boiled hard at least 
five minutes in a single boiler in order to prevent the formation 
of large curds. Simmering in a double boiler is not effective. 

Alkalis. — The addition of an alkali to milk unquestionably 
hinders or prevents the formation of large, hard curds in the 
stomach. There is much difference of opinion as to exactly how it 
does this and as to exactly what chemical changes take place in 
the gastric digestion of casein as the result of the addition of an 
alkali. The most probable explanation of these differences of 
opinion is that the exact details of the digestion of casein are even 
now but imperfectly understood. The nomenclature of the various 
products which are formed is, moreover, not a settled one. The 
1 Journal A. M. A., 1913, lx, 575. 



204 DISEASES OF NUTRITION 

coagulation of the milk in the stomach by rennin is unquestionably 
delayed by the addition of an alkali, because rennin does not act in 
an alkaline medium. How much it is delayed depends, with a 
given amount of alkali, on the acidity of the milk, which in clinical 
work is always an unknown quantity. The more acid the milk, the 
more of the alkali is required to neutralize it and the less is left to 
neutralize the hydrochloric acid secreted by the stomach and vice 
versa. When pure, clean milk is used, the part played by the 
acidity of the milk is probably relatively unimportant. During 
this period of delay it is generally believed that some of the un- 
coagulated milk leaves the stomach, the amount of milk which 
passes into the duodenum varying directly with the length of time 
before coagulation takes place. Certain authorities claim that the 
milk cannot leave the stomach under these conditions, because the 
pylorus does not open until the reaction on the stomach side is 
acid. Others state that milk, before it is coagulated, leaves the 
stomach quickly in gushes, like water, independent of the pyloric 
reflex. 1 When coagulation does occur the curds formed are more 
granular and softer than the tough curds of calcium paracasein 
which are ordinarily formed. 

Whatever the action of the alkali may be, there is no doubt that 
it consists partly in neutralizing the acidity of the milk and partly 
in neutralizing the hydrochloric acid secreted by the stomach, 
thereby changing the combination of the calcium salts with casein. 
It is evident, therefore, that, as regards the neutralization of the 
acidity of the milk, whatever alkali is used, the amount to be 
added to the food should be determined by the amount of milk and 
cream in the food, which determine its acidity and which alone 
contain casein, not in relation to the total quantity of the mixture. 
It is impossible in ordinary clinical work to know how much alkali 
to add, because the acidity of the milk is always an unknown 
quantity. Experience has shown, however, that, when lime water 
is used as the alkali, from 25 to 50% of lime water must be added 
to average milk in order to produce any appreciable effect. 

Bicarbonate of soda or other alkalis are sometimes used in place 
of lime water. One and one-half grains of bicarbonate of soda is 
equal to about an ounce of lime water. The action of lime water 
and bicarbonate of soda is, however, somewhat different. Lime 
water swells the mucoid protein of milk, which probably has some 
effect on the precipitation of the casein, while the carbonic acid 
gas which is formed from bicarbonate of soda during digestion tends 
to make the curds more porous. 

1 Cannon: The Mechanical Factors of Digestion, 1911, p. 115. 



AND INFANT FEEDING 205 

Citrate of Soda. — Citrate of soda is of considerable value in 
the prevention of the formation of large, tough curds. Under 
ordinary conditions rennin splits calcium caseinate into calcium 
paracaseinate which is insoluble. The citrate of soda combines 
with the calcium caseinate of the milk to form sodium caseinate 
and calcium citrate. Rennin splits sodium caseinate into sodium 
paracaseinate, which is very soluble. Therefore no precipitation 
or curdling takes place. 1 One or two grains of the citrate of 
soda to the ounce of milk or cream in the mixture is the quantity 
usually employed. Two grains to the ounce is probably more 
effective than one grain. 

Buttermilk. — The casein in buttermilk and other forms of milk 
in which lactic acid forming organisms have been allowed to grow 
is in a form in which it cannot be acted upon by rennin. The 
formation of large, hard curds is, therefore prevented. The casein 
is said to be in the form of the lactate of casein, this having been 
formed as the result of the combination of the lactic acid produced 
by the bacteria with the casein. This statement seems very 
doubtful, however, as casein acts as an acid and two acids cannot 
combine. Some of the casein has also presumably been more or 
less digested by bacterial action. The casein in buttermilk is in a 
finely divided condition as the result of the mechanical action of 
the churning. Boiling buttermilk does not affect the chemical 
combination of the casein. 

Protein Milk. — A considerable part of the casein in the so-called 
Eiweissmilch or, in English, protein or albumin milk, has already 
been precipitated by rennin in the form of calcium paracasein. 
When taken into the stomach it, therefore, cannot be acted upon 
again by rennin. The paracasein curds have been, moreover, very 
finely divided by being rubbed through sieves in the preparation of 
the food. The casein furnished by the buttermilk in the food is, as 
has already been explained, in the form of the " lactate of casein." 
The formation of large, tough curds in the stomach is, therefore, 
impossible. 

Pancreatization. — Another method of preventing the formation 
of large curds is by the partial predigestion of the food. This 
is commonly known as peptonization but is in reality pancreatiza- 
tion, the active ferment being the trypsin of the pancreas. A part, 
at least, of the casein is so far digested that it cannot be acted 
upon by rennin. The formation of hard curds in the stomach is, 
therefore, more or less interfered with, the amount of interference 

1 Bosworth and Van Slyke: Technical Bulletin No. 34, New York Agri- 
cultural Experiment Station. 



206 DISEASES OF NUTRITION 

depending on how far the process of pancreatization has been 
carried. 

Salts— The various salts, with the exception of iron, are present 
in sufficient quantities and in proper proportions in human milk. 
In most modifications of cow's milk there is an excess of salts and 
the proportions of the various salts are different from those in 
human milk. The normal infant can, as a rule, thrive in spite of 
this excess of salts and in spite of their, for the infant, abnormal 
relation to each other. There is no doubt, however, that a part, 
perhaps a considerable part of the disturbances of digestion in 
infants fed on modifications of cow's milk are due to the excess and 
abnormal relations of the salts in them. It does not seem reason- 
able, nevertheless, to go as far as some pediatricians and attribute 
all the disturbances of digestion to them. At present, however, our 
knowledge concerning the salts, the part which they play in normal 
digestion and metabolism and the symptoms of the disturbances 
which they cause is so limited and incomplete that we can pay but 
little attention to them in the regulation of the diet either in health 
or in disease. 

The Relation of the Different Elements of the Food to Each 
Other. — Thus far the different elements of the food and the dis- 
turbances of digestion to which they may give rise have been con- 
sidered as if they always occurred independently of each other. 
This point of view is, however, a mistaken one. It is wrong to 
think so much, as is now the custom, of the disturbances of diges- 
tion caused by single elements of the food. There can be no doubt 
that in many instances in which the disturbance appears to be 
due to a single element, the real trouble is in the relation of the 
different elements to each other. Our knowledge of the connection 
of the disturbances of digestion with the various food elements is 
still extremely rudimentary, and we must be very careful not to 
accept each new item of information as the final solution of the 
problem. 

Special Preparations of Milk used in Infant Feeding. — Various 
special preparations of milk have been used in infant feeding with, 
according to those who have employed them, unusually favorable re- 
sults. The most important of them are buttermilk and protein milk. 

Buttermilk. — Buttermilk made from sweet milk in the manufac- 
ture of butter is, of course, nothing but skimmed milk. It con- 
tains from 0.50% to 1.0% of fat, about 4.5% of milk sugar and 
3.8% of protein, the relation of the casein and the whey protein 
being the same as in whole milk. 

Buttermilk is usually made from cream soured either naturally 



AND INFANT FEEDING 207 

or by the addition of lactic acid bacteria. The composition of 
buttermilk obtained in this way is not a constant one. Average 
figures are: fat, 0.5% to 1.0%; milk sugar, 3.0% to 3.5%; pro- 
tein, 2.5% to 2.7%. The proportion of whey protein is relatively 
higher than in whole milk. The casein is very finely divided as the 
result of the centrifugalization and is separated from its calcium 
base. It is already clotted in the form of the "lactate of casein" 
and can no longer be acted upon by rennin. The caloric value of 
buttermilk varies between 300 and 400 calories per liter. A fair 
average figure is 360 calories per quart. 

Good buttermilk should not contain over 0.50% of lactic acid. 
There is a tendency for the acidity to increase with time, although 
it rarely reaches over 0.75%, at which point the buttermilk sep- 
arates into curds and whey. The lactic acid organisms which 
caused the souring of the milk, as well as other organisms, are alive 
and active. Heating buttermilk destroys the fine division of the 
casein and causes it to clot in large masses like ordinary cow's 
milk. It also destroys the bacteria which it contains. Heated 
buttermilk is, therefore, no better than sour skimmed milk. This 
clotting may be prevented by constant, violent stirring or beating 
while it is being heated. 

Buttermilk has been used as a food for infants since at least as 
early as 1770, and good results have unquestionably been obtained 
with it. This is readily understood when its composition is remem- 
bered. It contains a low percentage of fat, a rather low percentage 
of sugar and a relatively high percentage of protein, the proportion 
of whey protein being relatively greater than in plain milk. The 
casein is finely divided and in a form which cannot be acted on by 
rennin. It is highly acid from the presence of lactic acid and con- 
tains many bacteria, the lactic acid forms predominating. It 
should be useful, therefore, in those conditions in which a low fat 
and a high, easily digestible protein is indicated. The lactic acid 
organisms which it contains should also be of advantage in those 
disturbances of digestion which are due to organisms to which 
the lactic acid bacteria are antagonistic. This possible advantage 
is lost, of course, when buttermilk is pasteurized or boiled. 

Most of those who have employed and recommended the use of 
buttermilk as a food for infants have, however, not used it plain. 
They have added from 10 to 25 grams of flour, usually wheat, 
and from 35 to 90 grams of cane sugar to a liter of buttermilk and 
then boiled it with much stirring. The nutritive value of the 
buttermilk is thus materially increased, while the other char- 
acteristics are unchanged, except that the lactic acid bacteria are 



208 DISEASES OF NUTRITION 

destroyed. The caloric value of buttermilk prepared in this way 
varies between 525 and 700 calories per liter, the additional 
calories being furnished by the cane sugar and starch which have 
been added. 

It does not seem rational to use buttermilk, with or without the 
addition of cane sugar and starch, as a routine food for all babies, 
whether sick or well. It is far more reasonable to adopt the good 
points in it and utilize them in combination with percentage feed- 
ing. 1 There is no special advantage in using buttermilk in cases in 
which a low percentage of fat is indicated, because a low percentage 
of fat can be more easily given in other ways. The peculiar form of 
the casein in buttermilk may be of considerable value in instances 
in which there is a disturbance of the digestion of casein. If plain 
buttermilk or stock preparations of buttermilk are used, the 
percentages of fat and sugar cannot be varied to suit the needs of 
the individual baby. If a modified milk is prepared to fit the needs 
of the individual infant at the time and the character of the casein 
then changed by the action of lactic acid bacteria, the chief ad- 
vantage of buttermilk is thus retained and yet the food is in other 
ways fitted to the needs of the baby. It is probable that the 
degree of the acidity of the buttermilk plays some part in its 
action. This cannot be regulated in commercial buttermilk, but 
can be when the milk is soured by the addition of lactic acid 
bacteria, since the production of acid can be stopped at any time 
by boiling the mixture. When the change in the character of the 
protein is all that is desired, the mixture should be boiled when the 
acidity is between 0.25% and 0.50%. Twenty-five hundredths 
per cent of lactic acid just curdles milk while 0.50% gives thick 
curdled milk. An acidity of from 0.50% to 0.70% is usually at- 
tained in from twelve to eighteen hours. 

When the action of the lactic acid bacteria on the intestinal 
bacteria is what is desired, the mixture should not, of course, be 
boiled. The acidity should not, however, run much above 0.50%. 

Other objections to the use of commercial buttermilk are that 
the acidifying organisms are usually of several varieties and that 
the milk contains a variety of other organisms which have grown 
at the same time, many of which are undesirable. It is far wiser, 
therefore, to prepare foods for babies by the addition of pure cul- 
tures of lactic-acid-forming organisms to pure or boiled milk. The 
danger of infection by other organisms is thus avoided. The 
bacillus Bulgaricus is the one perhaps most commonly used. It is 
liable, however, to make the taste of the milk too acid. Another 
1 Morse and Bowditch: Archives of Pediatrics, 1906, xxiii, 889. 



AND INFANT FEEDING 209 

organism, perhaps better, is the bacillus acidi paralactici. Cul- 
tures of lactic-acid-forming organisms are now easily obtainable 
from milk laboratories and chemists. Better results are usually 
obtained by the use of a "starter" than by the use of a new culture 
each time. 1 Cultures are much preferable to the various lactic acid 
tablets on the market, many of which are inert and none of which 
are as active as cultures. 2 

Protein Milk (Eiweissmilch, Casein Milk, Albumin Milk). — 
Finkelstein and Meyer conclude from their observations that 
sugar is the special and primary cause of intestinal fermentation 
and that the fat is never involved primarily. They believe that 
the fermentation of the sugar is dependent on two main factors: 
the concentration of the whey and the relative proportions of 
casein and sugar in the mixture. They conclude, therefore, that 
the principles on which the preparation of a food to combat intes- 
tinal fermentation depend are: a diminution in the quantity of 
milk sugar, a diminution of the salts through dilution of the whey, 
and an increase in the casein, with varying, and, under certain cir- 
cumstances, not inconsiderable amounts of fat. After improve- 
ment has begun, an easily assimilable and consequently little 
fermentable carbohydrate should be added. They consequently 
developed a food to meet these indications to which they gave the 
name of Eiweissmilch. This food is prepared as follows : Heat one 
quart of whole milk to 100° F. Add four teaspoonfuls of essence of 
pepsin and stir. Let the mixture stand at 100° F. until the curd has 
formed. Put the mass in a linen cloth and strain off the whey 
from the curd. Remove the curd from the linen cloth and press it 
through a rather fine sieve two or three times by the means of a 
wooden mallet or spoon. Add one pint of water to the curd during 
this process. The mixture should now look like milk and the 
precipitate must be very finely divided. Add one pint of butter- 
milk to this mixture. 

Finkelstein and Meyer used buttermilk in the preparation of 
this food for the following reasons: 1, because of the small amount 
of milk sugar which it contains; 2, to obtain the good effects of the 
lactic acid, and 3, because buttermilk can be kept for a long time, 

The composition of this food is: 

Fat : 2.5% 

Sugar 1.5% 

Protein 3.0% 

Salts 0.5% 

1 Morse and Bowditch: Archives of Pediatrics, 1906, xxiii, 889. 
2 Heinemann: Jour. Amer. Med. Ass'n, 1909, lii, 372, and 1912, Iviii, 1252. 



210 DISEASES OF NUTRITION 

One quart of this milk contains about 370 calories. 

They call attention to the low caloric value of this food and to 
the necessity of increasing it as soon as possible by the addition of 
dextrin-maltose mixtures. 

They claim that it is worthy of employment in all the disturb- 
ances of nutrition in infants which are accompanied by diarrhea 
of no matter what sort or variety. The use of this food has been 
extended by others to all sorts of conditions, including the feeding 
of well infants and the newly-born, and good results claimed for it. 

The principle of the treatment of fermentative conditions caused 
by sugar with a food low in sugar and salts and high in protein is 
a rational one, as is the substitution of the dextrin-maltose mix- 
tures for lactose. It hardly seems rational, however, to believe 
that all disturbances of nutrition accompanied by diarrhea are 
due to the same cause and should be treated in the same way. 
Neither does it appear reasonable to think that any method of 
feeding can be applicable to both the sick and the well or to give 
all babies the same food without regard to their individual digest- 
ive capacities. 

It is possible, however, to take advantage of the main principles 
of this method of treatment of the intestinal fermentative condi- 
tions and at the same time avoid the disadvantages of a routine 
food by applying them in the modification of milk by the percent- 
age method. The buttermilk seems to be an unnecessary addition, 
because the low salt and high casein content, which form the 
raison d'etre of the food, can be obtained perfectly well without it. 
It is possible by the use of cream containing a high percentage of 
fat to reduce the amount of unprecipitated casein and whey protein 
to a very small percentage and yet have any desired percentage 
of fat in the mixture. The percentages of salt and sugar are also 
kept low because of the small amount of cream required. Any per- 
centage of casein desired can then be added in the form of precip- 
itated casein prepared according to Finkelstein and Meyer's 
method. The advantages of this method of treatment of ferment- 
ative intestinal conditions are retained in this way and the dis- 
advantages of a routine method avoided. The dextrin-maltose 
mixtures can be added, of course, when desired, and the percent- 
age of salt increased by the substitution of creams containing 
lower percentages of fat. 

The preparation of protein milk and of modifications of milk 
made with precipitated casein is a difficult matter outside of milk 
laboratories or institutions. This method of treatment is, there- 
fore, hardly applicable in the home. The addition of dried, pow- 



AND INFANT FEEDING 211 

dered casein and paracasein to mixtures made in the ordinary way, 
as suggested by Bowditch and Bosworth 1 offers another method 
of combining low percentages of sugar and salts with a high per- 
centage of casein. This method is, moreover, much simpler and 
can be carried out in the home as well as in institutions or milk 
laboratories. 

1 Amer. Jour. Diseases of Children, 1913, vi, 394. 



212 DISEASES OF NUTRITION 



CHAPTER XVIII 
THE PRESCRIBING OF MODIFIED MILK 

The first thing to do in prescribing modified milk for an infant 
is to determine what percentages of fat, sugar, protein and starch 
shall be in the mixture. The next things to decide are whether the 
sugar shall be in the form of milk sugar, cane sugar or one of the 
dextrin-maltose mixtures and whether a part of the protein shall 
be given in the form of whey protein or not. It is then necessary 
to determine whether an alkali shall be added or not and, if it is 
added, what form shall be used and how much of it. Finally it 
must be decided whether the mixture shall be given raw, pasteur- 
ized, and if so, at what temperature, or boiled. After all these 
points are settled, the number of feedings and the amount at each 
feeding must be decided, bearing in mind in this connection that 
the total quantity given in the twenty-four hours is far more im- 
portant than the number of feedings and the size of the individual 
feeding. It is advisable, after deciding upon the total quantity, 
to calculate the caloric value of the food and the amount of protein 
which it contains in order to know whether the caloric and protein 
needs are being covered or greatly exceeded. In most instances 
the food decided upon should be given, even if its caloric and pro- 
tein content do not correspond to the established standards. The 
knowledge of these points will, however, often prove of great assist- 
ance in changing the food in the future, if the baby does not thrive 
on it. In special cases it is also necessary to determine whether 
the mixture shall be acted upon by lactic acid organisms or not, 
and, if so, whether or not they shall be destroyed by heat; in others, 
whether some form of protein milk (Eiweissmilch) shall be used or 
the milk pancreatized. 

Every one of these points must be decided every time that a 
modified milk mixture is prescribed. No single one of them can 
be omitted. They must be decided, moreover, not by following 
blindly the rules of some authority on infant feeding or by picking 
a formula from a table in some text-book, but on the indications 
in the given case at the given time. 

When the composition and the amount of the food have been 
decided, the food may be prepared either at a milk laboratory or in 



AND INFANT FEEDING 213 

the home. When the milk is to be prepared at a milk laboratory, 
it is only necessary to write a prescription for the food, embodying 
the points already determined. Most milk laboratories have a 
prescription form in which it is only necessary to fill in the blank 
spaces. This form, while a convenience, is in no way a necessity. 
The physician who is competent to prescribe modified milk mix- 
tures has no need of a form. On page 214 is a copy of the prescrip- 
tion form furnished by the milk laboratories in the neighborhood 
of Boston. 

There is no doubt that a milk laboratory can prepare mixtures 
of modified milk more accurately than they can be prepared in the 
home. The milk and cream can be analyzed daily in the laboratory 
and the sugar and starch accurately weighed, so that the mixtures 
can be made from materials of known composition. This cannot 
be done in the home. Whether the formulae are actually put 
up more accurately in the laboratory than in the home depends, 
however, on the care exercised in the individual laboratory at the 
given time. The employees in milk laboratories are human and 
are, therefore, liable to be careless and to make mistakes. Another 
advantage which the milk laboratories have is that they own their 
own farms and can, therefore, be sure of having a clean milk from 
which to prepare the food. The individual preparing the food at 
home, unless able to procure a certified milk, can never be sure 
whether the milk is clean or not. 

The price of modified milk, prepared at milk laboratories, is no 
higher than it should be, when the character of the materials used, 
the labor required in the modification of the milk and the cost of 
delivery are taken into consideration. The price is, nevertheless, 
prohibitive for poor people. If the milk has to be sent any distance 
and express charges added, only the well-do-to can afford to have 
it. Comparatively few babies can be fed, therefore, on modified 
milk prepared at a milk laboratory. The vast majority, either 
because of the expense or the distance from a laboratory, must be 
fed on mixtures prepared in the home. 

THE HOME MODIFICATION OF MILK 

Modifications of milk for infant feeding cannot be prepared as 
accurately in the home as at a milk laboratory, because it is im- 
possible in the home to know the exact composition of the materials 
used in the preparation of the mixtures. If reasonable care is used 
in their preparation, however, the inaccuracies are not as great as 
would be supposed. In fact, in the vast majority of instances, 



214 



DISEASES OF NUTRITION 



R 

Fata 



Per Cent. 



(a) Carbohydrates 



(b) Dextrinize 



Lactose (Milk Sugar) 
Maltose (Malt Sugar) 
Sucrose (Cane Sugar) 
Dextrose (Grape Sugar) 
Starch 



(d) Peptonize 

(e) Sodium Citrate j 



(f) Sodium Bicarb. | 

(g) Lime Water j % 



(h) 



Lactic Acid 
Bacillus 



% of milk and cream 
% of total mixture 

% of milk and cream 
% of total mixture 

of milk and cream 
of total mixture 

To inhibit the saprophytes of fer- 
mentation 

To facilitate digestion of the pro- 
teida 



Heat at 



_°F. 



Number of Feedings 



Amount at each Feeding. 



ORDERED FOR 



ADDRESS- 
DATE 



19 
_M. D. 



EXPLANATORY 



(a) It requires 0.75% starch to make 
the precipitated casein finer. 

(b) One hour completely dextrinises 
the Starch. 

(c) In case physicians do not wish to 
sub-divide the proteids, the words 
"Whey" and "Casein" may be erased. 

(d) Twenty minutes renders the mix- 
ture decidedly bitter. 

(e) It requires 0.20% of the milk and 
cream used in modifying to facilitate 
the digestion of the proteids; i. e., the 
formation of a soft curd. 0.40% to pre- 
vent the action of rennet; i. e., the 
formation of tough curd. 

(f) It requires 0.68% of the milk and 
cream used in modifying to favor the 
digestion of the proteids. 1.70% of the 
amount of milk and cream used sus- 
pends all action on the proteids in the 
stomach. 0.17% of the total mixture 
gives a mild alkaline food. 



(g) It requires 20% of the milk and 
cream used in modifying to favor the 
digestion of the proteids. 50% of the 
amount of milk and cream used sus- 
pends all action on the proteids in the 
stomach. 5% of the total mixture gives 
a mild alkaline food. 

(h) Percentage figures represent the 
per cent of Lactic Acid attained when 
the food is removed from the thermo- 
stat. When the Lactic Acid Bacillus is 
used to facilitate digestion of the pro- 
teids, this is the final acidity, as the 
process is stopped by heat at this point. 
When the Lactic Acid Bacillus is used 
to inhibit the growth of saprophytes, 
the acidity may subsequently increase to 
a variable degree, as the bacilli are left 
alive. 0.25% Lactic Acid just curdles 
milk. 0.50% gives thick curdled milk. 
0.75% separates into curds and whey. 



AND INFANT FEEDING 215 

they are not great enough to disturb the digestion or to interfere 
with the nutrition and development of babies fed upon them. 
The average infant fortunately does not notice small variations in 
the composition of an artificial food any more than it does similar 
variations in the composition of breast-milk. Extreme accuracy 
is necessary only in exceptional cases. In general, therefore, the 
modifications of milk prepared at home are sufficiently accurate 
for all practical purposes and it is rarely necessary on this account 
to have recourse to a milk laboratory. When practicable, it is, 
however, much easier, and in most instances will be found more 
satisfactory, to have modified milk prepared at a laboratory 
rather than at home. 

It is often said that the calculation of the formulae for the prep- 
aration of modified milk at home is too complicated for the average 
physician to carry out and that it requires more time than the busy 
practitioner can give to it. These statements are distinctly not 
true. There is nothing about the calculation of formulae suffi- 
ciently accurate for practical purposes which cannot be understood 
by anyone with even an elementary knowledge of arithmetic. 
If a physician cannot understand the principles involved, there 
must have been some mistake made when his degree was granted. 
There is no more reason why a physician should not take the time 
to calculate a proper modification of milk for a baby than why he 
should not take the time to sterilize his hands before an abdominal 
operation. He is equally negligent in either case, if he does not. 
As a matter of fact, however, it requires but little time to calculate 
a formula, if the physician knows how to do it. Five or, at the 
most, ten minutes is amply sufficient. 

It is also not infrequently said that the procedures involved in the 
preparation of modifications of milk in the home are too compli- 
cated for the ordinary mother or nurse maid to comprehend and 
carry out. This statement is also untrue. There is nothing about 
the preparation of modified milk in the home which any woman 
of average intelligence cannot understand and do, provided it is 
properly explained to her. The trouble is not with the women, but 
with the physicians who, either through ignorance or carelessness, 
neglect to explain the details of the preparation of the food to them. 

In prescribing for modified milk to be prepared in the home it is 
necessary to determine not only what food shall be given to the 
baby, but also how this food shall be prepared. It is of great 
importance, in the first place, to be sure that the milk which is to 
be used is a clean milk. It is impossible to make a good food from 
dirty milk, no matter how much it is modified. 



216 DISEASES OF NUTRITION 

It is also of considerable importance to employ milk which is 
reasonably constant in its composition. This is best done by using 
certified milk. Modifications prepared from ordinary milk, pro- 
vided it is not from Jersey cows or similar breeds, are, however, in 
most instances sufficiently accurate in places where there is a 
legal standard for milk. When there is a doubt as to the composi- 
tion of the milk, it is not a difficult matter to determine it approx- 
imately. 

The fat content of milk can be accurately determined in a few 
minutes with one of the small hand Babcock milk testers. A very- 
satisfactory two bottle machine, The " Facile Jr.," is made by 
D. H. Burrell and Co., of Little Falls, N. Y. The price with 
bottles, pipette and measuring glasses is $4.50. It is important in 
making this test to use sulphuric acid of a specific gravity of from 
1.82 to 1.83 at 60° F. The total solids can be easily determined in 
a few minutes with a lactothermometer and a Richmond "Milk 
Slide Rule." These, with directions for their use, may also be pro- 
cured of D. H. Burrell and Co., the price of the lactothermometer 
being from $1.00 to $1.50, and that of the Richmond "rule" $2.50. 
The percentage of fat and the total solids being known and the 
percentages of the ash and sugar being fairly constant, the per- 
centage of the protein can be approximately determined with rea- 
sonable accuracy by subtracting the sum of the percentage of fat 
and the estimated percentages of the sugar and ash from the per- 
centage of the total solids. The percentage of casein can be readily 
determined in from fifteen to twenty minutes by the volumetric 
method of Van Slyke and Bosworth, if more accurate results 
are desired. 1 Multiplying the percentage of casein by 1.4 gives 
the percentage of the total protein accurately enough for practical 
purposes. 

Composition of Materials used in the Home Modification of 
Milk. — It being impossible, except in rare instances, to analyze the 
milk and cream used in the preparation of modified milk in the 
home, it is necessary to adopt certain arbitrary standards as to the 
composition of these substances. It must be remembered that any 
form of milk containing more than 4% of fat is technically cream. 
It is wrong, therefore, to think and speak of cream as a definite 
entity, without qualification. It is more correct to think of creams, 
with the fat content always specified. The following figures 
(Table 43) as to the composition of the various creams, whole 
milk, skimmed milk and whey are approximately correct. 

1 New York Medical Journal, 1909, xc, 542. 



AND INFANT FEEDING 



217 



TABLE 43 



Fat 



Milk sugar 



Protei 



Whole milk 

7% cream 

10% cream 

16% cream 

32% cream 

Skimmed milk 

Separated milk ("fat free") 
Whey 



4.00 

7.00 

10.00 

16.00 

32.00 

1.00 

0.25 

0.25 



50 
45 
40 
20 
40 
00 
00 



5.00 



3.50 
3.40 
3.25 
3.05 
2.50 
3.55 
3.65 
0.90 



If milk is allowed to set six hours or longer, the upper sixteen 
ounces of a quart of bottled milk contains 7% and the upper ten 
ounces 10% of fat. The cream layer, that is "gravity cream/' 
without regard to how many ounces of it there are on a quart, 
contains about 16% of fat. If the whole milk from which cream is 
obtained contains more than 4% of fat, the cream will contain a 
proportionally larger amount. Ordinary "thick cream/' as it is 
called, contains, on the average, 32% of fat. The composition of 
this type of cream is, however, very variable, so variable indeed 
that it is hardly safe to use it in the preparation of modified milk, 
unless the percentage of fat is known. 

Skimmed milk is the milk which is left after the gravity cream 
has been removed by a dipper or by pouring. If some of the upper 
layers of the milk are removed in addition to the cream, the part 
which is left contains less than 1% of fat. Separated ("fat free") 
milk is the milk which is left when the cream has been removed by 
centrifugalization. The whey obtained from separated milk con- 
tains 1% of protein. 

Table 44 copied from Chapin and Pisek, 1 shows the percentage 
of fat in each of the top nine ounces of a quart of bottled milk 
which has set six hours or longer, and the fat content of the 
top ounces, from two ounces to thirty ounces, under the same 
conditions. 

It is evident that "top milk" may mean any number of ounces, 
from one to thirty-one ounces, from a quart. It is also evident that 
the so-called "top milks" are merely creams of varying per- 
centages and that modifications of milk made from "top milks" 
differ in no way from those made from creams except in name. 
Since top milks vary as much in their fat content as do creams, it is 
evidently just as important in prescribing for the preparation of 



1 Diseases of Children, 1909, p. 138. 



218 



DISEASES OF NUTRITION 



TABLE 44 

First ounce contains 25.0% fat 

23.0% 

19.0% 

18.5% 

10.5% 

• 4.8% 

3.4% 

2.2% 

1.8% 



Second 




tt 


Third 




a 


Fourth 




a 


Fifth 




a 


Sixth 




a 


Seventh 




it 


Eighth 




a 


Ninth 




ti 


Top 2oi 


mces 


mix 


3 


a 


a 


4 


ti 


a 


5 


it 


a 


6 


tt 


a 


7 


a 


a 


8 


ti 


a 


9 


a 


tt 


10 


it 


a 


12 


tt 


a 


14 


tt 


a 


16 


tt 


a 


18 


a 


it 


20 


tt 


a 


22 


tt 


a 


24 


a 


tt 


26 


tt 


ti 


28 


ti 


tt 


30 


tt 


tt 



.22.5% 

.21.4% 

.19.2% 

.16.8% 

.15.0% 

.13.3% 

11.5% 

.10.5% 

. 9.0% 

. 7.8% 

. 7.0% 

6.3% 

. 5.8% 

. 5.4% 

5.0% 

4.7% 

4.5% 

4.3% 



modified milk at home to specify exactly what top milk is to be 
used as it is to specify what sort of cream is to be used. 

Method of Calculation of Formulae for the Home Modification 
of Milk. — There are many methods for the calculation of the 
formulae for modifications of milk to be prepared in the home. 
Most of them are inaccurate in that the fat in the skimmed milk is 
disregarded, many of them in that the percentage of protein in the 
cream and skimmed milk is considered to be the same. All of them 
are accurate enough, however, for everyday work. It makes but 
little difference which method is employed, provided that method 
is understood and used correctly. It makes no difference whether 
gravity cream, 10% cream, top milks, skimmed milk or whole 
milk are used in the preparation of the mixtures. Equally good 
results can be obtained with all. The one important thing is that 
the food be calculated in percentages of the various food elements. 
It makes little difference how these elements are obtained. Meth- 
ods which take the fat in the skimmed milk and the differences in 



AND INFANT FEEDING 219 

the protein content of the various creams and milks into account 
are too complicated for ordinary, clinical use and are, fortunately, 
unnecessary. Those who wish to familiarize themselves with 
these different methods can find them fully described in two 
articles by Westcott. 1 

The writers have found the following method of calculation a 
satisfactory one in their own practice and have found that medical 
students understand it quickly and apply it easily and these are its 
chief recommendations. It is unquestionably inaccurate in many 
ways, as are all simple methods of calculation. It must be remem- 
bered, however, in criticizing methods of calculation for their 
inaccuracies, that, if the same method is used consistently, the 
inaccuracies are always similar and that different modifications of 
milk prepared by the same method are accurate relatively to each 
other. That is to say, if a baby who is taking a mixture supposed 
to contain 3.50% of fat, but which really contains 4% of fat, 
shows symptoms of fat indigestion, a reduction of 0.50% in the 
percentage of fat will have the same effect in relieving these 
symptoms, although it is a reduction from 4% to 3.50% instead of 
one from 3.50% to 3%, as it is supposed to be. That is, changes in 
the percentages are correct, even if the original percentages are 
incorrect. 

Gravity cream and skimmed milk are used in this method. The 
gravity cream is estimated to contain 16% of fat and the skimmed 
milk to be fat free. The mixtures, therefore, all contain a some- 
what higher percentage of fat than they are supposed to contain. 
The protein content of both the gravity cream and the skimmed 
milk is calculated to be 3.20%. This percentage is higher than 
that really present in the cream and lower than that in the 
skimmed milk. Numerous analyses, made by us by the Kjeldahl 
method, of the protein content of mixtures prepared in this way 
have shown, however, that the percentage of protein in them is 
not far from what it is calculated to be. They are much more 
nearly correct than would be expected. The percentage of sugar 
is estimated at 4.50 in both the gravity cream and skimmed milk. 

It may be well to define what is meant by gravity cream and 
skimmed milk once more before describing the method of calcula- 
tion. By gravity cream is meant all the cream which is visible on 
milk which has set for six hours or longer. All the cream must be 

1 The Scientific Modification of Milk. International Clinics, 1900, Tenth 
Series, hi, 233, and A Method for the Differential Modification of the Proteids 
in Percentage Milk Mixtures. American Journal Medical Sciences, 1901, 
oxxii, 439. 



220 



DISEASES OF NUTRITION 



removed and the required number of ounces taken from it. If 
there is not enough cream on one bottle, the cream must be re- 
moved from two bottles and mixed. The required number of 
ounces is then taken from the mixture of the two. The cream may 
be removed with a cream dipper or it may be poured off. The 
results obtained by pouring are not as accurate as those obtained 
by dipping. The same result may be obtained by siphoning off 
the milk below the cream and leaving the cream in the bottle. 
When a cream dipper is used, the first ounce must, of course, be 
removed with a spoon or the milk will be spilled when the dipper is 
introduced. Most bottled milk has been in the bottles many more 
than six hours before it is delivered. When the milk bottle is 
full, the cream rises even during transportation. It is not neces- 
sary, therefore, to wait six hours after the milk is delivered before 
preparing the food, provided the cream line is distinct. 

By skimmed milk is meant what is left after the gravity cream 
has been removed. The percentage of fat in the mixture will be 
more nearly correct if the lowest ounces are used instead of 
the same number of ounces from the whole of the skimmed 
milk. 

A rounded tablespoonful of milk sugar is considered in this 
method of calculation to weigh one-half an ounce. It will be 
found that this is not far from the true weight. By a rounded 
tablespoonful is meant what is contained in a tablespoon when 
it is dipped into milk sugar and then gently shaken, that is, it is 
rounded, not heaped or level. Every cook knows what is meant by 
this term. The weight of equal quantities of milk sugar and the 
dextrin-maltose mixtures is nearly enough the same for practical 
purposes. 

The estimated composition of the materials used in the prepara- 
tion of the mixtures is, therefore, as follows: 

TABLE 45 



Gravity cream 
Skimmed milk 
Milk sugar. . . 



Fat 



18.00% 

0.00% 



Milk sugar 



4.50% 
4.50% 



1 rounded tablespoonful = % ounce. 



Protein 



3.20% 
3.20% 



It is necessary, as always, before beginning the calculations as to 
the preparation of the food, to decide what percentages of fat, 
sugar and protein the food is to contain, how much is to be given 
in the twenty-four hours and how much lime water, if any, is to 



AND INFANT FEEDING 221 

be added. It is usually advisable to make the quantity large 
enough to allow for an extra bottle, so that, if a bottle is broken, 
the baby need not go hungry. 

Suppose that it is desired to prepare thirty-two ounces of a mix- 
ture containing 3% of fat, 6% of milk sugar and 2% of protein, 
with lime water enough to equal 25% of the milk and cream in the 
mixture. The fat in the food must be derived from the cream, 
because it is the only substance containing fat to be used in the 
preparation of the food. If the food was composed entirely of 
gravity cream it would contain 16% of fat. Since it is to contain 
but 3% of fat, it is evident that only three-sixteenths of the mix- 
ture must be gravity cream; T 8 ff of thirty-two ounces is six ounces. 
Six ounces of gravity cream will, therefore, provide the 3% of fat 
desired in the mixture. 

The gravity cream contains protein as well as fat. There are 
six ounces of gravity cream in the thirty-two-ounce mixture. The 
protein content of gravity cream is 3.20%. The protein content of 
a thirty-two-ounce mixture containing six ounces of gravity cream 
is evidently %% of 3.20%, or 0.60%. Two per cent of protein is 
however, desired in the mixture. The gravity cream has provided 
only 0.60%. One and forty hundredths per cent of protein, the 
difference between the percentage of protein desired and that fur- 
nished by the gravity cream, must be obtained in some other way. 
It must be obtained, moreover, from some substance which does 
not contain fat. Skimmed milk is such a substance. Skimmed 
milk contains 3.20% of protein. In order to get 1.40% of protein 
in the mixture by the use of skimmed milk, it is evident that J;|$ 
of the mixture must be skimmed milk; Jf $ of thirty-two ounces is 
fourteen ounces. Fourteen ounces of skimmed milk will, therefore, 
provide the additional 1.40% of protein desired. 

Both gravity cream and skimmed milk contain 4.50% of milk 
sugar. Twenty ounces of gravity cream and skimmed milk are 
required to furnish the desired percentages of fat and protein. 
These twenty ounces in a thirty-two-ounce mixture must add |-| 
of 4.50% of sugar to the mixture. Twenty thirty-seconds of 4 J, or 
If of f = W -, or practically 3% of milk sugar. It is, however, 
desired to have 6% of milk sugar in the mixture. That is, 3% more 
of milk sugar is required. This additional sugar must be added in 
the form of dry milk sugar. Three per cent of thirty-two ounces is 
T |^ of thirty-two. This will give the amount of sugar desired in 
ounces. The sugar is to be measured in rounded tablespoonfuls, 
or half ounces. If the figures given above are multiplied by two, 
the result will be the number of rounded tablespoonfuls needed. 



222 



DISEASES OF NUTRITION 



That is, T | TF of 32 x 2 = } jj-f rounded tablespoonfuls, or for all prac- 
tical purposes, two rounded tablespoonfuls. 

It is also desired to have an amount of lime water in the mixture 
equal to 25% of the cream and milk in the mixture. There are 
twenty ounces of cream and milk in the mixture. Twenty-five per 
cent of twenty ounces is five ounces. Five ounces of lime water 
must, therefore, be added. The total quantity of the mixture is to 
be thirty-two ounces. The mixture is to contain six ounces of 
gravity cream, fourteen ounces of skimmed milk and five ounces of 
lime water, that is, twenty-five ounces. The milk sugar goes into 
solution and, therefore, does not add to this quantity. The 
difference between thirty-two ounces and twenty-five ounces is 
seven ounces. Seven ounces of water must, therefore, be added to 
make up the quantity desired. The following table shows the 
results of the steps just described. 





TABLE 46 








Ounces 


Fat 


Sugar 


Protein 


Gravity cream 

Skimmed milk 

Milk sugar 

Lime water 

Water 


6 

14 

2 rounded table- 
spoonfuls 
5 

7 

32 


3.00 


J3.00 
3.00 


0.60 
1.40 




3.00 


6.00 


2.00 



The milk sugar should be dissolved in the seven ounces of hot 
water. The water should be allowed to cool and then be mixed 
with the other ingredients. 

Mixtures containing Starch. — It is as important to have the 
percentage of starch in the food accurate as it is to have those of 
the fat, sugar and protein. Starch is usually added in the form of 
the cereal waters. The strength of the cereal water which is to be 
used in the preparation of the food must be known, therefore, 
in order to get the desired percentages of starch in the mixture. 

Two rounded teaspoonfuls of barley or oat flour to the pint of 
water give a 1.50% decoction of starch, while four rounded tea- 
spoonfuls to the pint of water give a 3% decoction. The flour 
should be mixed with a small amount of water, after which the 
remainder of the water is added. The mixture is then boiled for 
twenty minutes, after which, as some of the water has boiled away, 
enough hot water is added to make up the original pint. It should 



AND INFANT FEEDING 223 

then be strained through several thicknesses of cheesecloth. It 
should be cooled before being mixed with the milk and cream. 

If it is desired to have 0.75% of starch in a mixture and a cereal 
water containing 1.50% of starch is to be used, it is evident that 
one-half of the mixture must be made up of the cereal water. 
If a 3% cereal water is used, one-quarter of the mixture will be re- 
quired to give 0.75% of starch. Suppose that it is desired to have 
0.75% of barley starch in the mixture which has just been cal- 
culated. In order to get 0.75% of starch in a thirty-two-ounce 
mixture, using 1.50% barley water, it will be necessary to use 
jj z \ of thirty-two ounces, or sixteen ounces. The mixture already 
contains twenty-five ounces of gravity cream, skimmed milk and 
lime water, leaving room for only seven ounces of barley water. 
It is plain, therefore, that it is impossible to have 0.75% of starch 
in the mixture, if 1.50% barley water is used. If 3.00% barley 
water is used, J; J J of thirty-two ounces, or eight ounces will be 
required. There is room for only seven ounces. The difference 
in the percentage of starch added when seven or eight ounces are 
added is only 0.10%, which is a negligible amount. Seven ounces 
of 3.00 barley water will, therefore, be sufficient. 

If preferred, the amount of starch to be added to a mixture to 
give any percentage required of starch in the mixture may be cal- 
culated directly. Suppose, for example, it is desired to have 1.00% 
of barley starch in a forty-eight-ounce mixture. One per cent of 
forty-eight ounces is T £ 7 of forty-eight ounces, or practically one- 
half an ounce. Two rounded teaspoonfuls or one rounded table- 
spoonful of barley flour weighs one-half an ounce and will, there- 
fore, add 1% of barley starch to the mixture. This amount of 
barley flour should be cooked in the number of ounces of water in 
the mixture and then mixed with the gravity cream and skimmed 
milk. 

Whey Mixtures. — It is impossible to make mixtures containing 
a high percentage of whey protein with a low percentage of casein, 
provided they contain more than one or 2% of fat, if gravity cream 
is used in the preparation of the food, as it usually is in the home. 
The reason of this is that the gravity cream which it is necessary 
to use in order to get the desired percentages of fat contains a con- 
siderable amount of protein and by its bulk diminishes the amount 
of whey and consequently the amount of whey protein which can 
be added. It is usually desired, when whey protein is prescribed, 
to have as much of it in a mixture as is possible. For practical 
purposes, therefore, when whey mixtures are prepared in the home 
with gravity cream, the amount of gravity cream required to give 



224 DISEASES OF NUTRITION 

the desired percentage of fat is calculated and the rest of the mix- 
ture made up with whey, the amount of whey protein added being 
determined later. Smaller percentages of whey protein can be 
added, of course, if desired. 

Suppose that it is desired to give a baby a twenty-four-ounce 
mixture containing 3% of fat and 6% of sugar, with lime water 
10% of the cream in the mixture; T 8 ff of twenty-four ounces is 
four and one-half ounces. Four and one-half ounces of gravity 
cream will, therefore, be required. This will put -^ l i~ of 3.20%, or 
0.60%, of protein in the mixture. This protein is chiefly in the 
form of casein. Ten per cent of four and one-half ounces is nearly 
one-half an ounce. One-half an ounce of lime water must, there- 
fore, be added. It is evident that there is room for nineteen ounces 
of whey in the mixture, the difference between twenty-four and 
4| + J, being nineteen. The composition of whey for practical 
work in the home modification of milk may be calculated to be 
|f of 0.90% of whey protein gives 0.70 of whey protein, which is the 
amount added by the whey. 



Whey 



Fat 



0.00 



Milk sugar 



4.50 



Whey protein 



0.90 



Both the gravity cream and the whey contain 4.50% of milk 
sugar. There being but one-half ounce of lime water in the whole 
mixture, it already contains approximately 4.50% of milk sugar. 
It being desired to have 6% of milk sugar in the mixture, 1.50% 
more must be added in the form of dry milk sugar; \-fcf- of 24 x 2 = 
0.72 of a rounded tablespoonful. A level tablespoonful of milk 
sugar will, therefore, just about make up the required percentage 
of sugar. 

The mixture contains 3% of fat, 6% of sugar, 0.70% of whey 
protein and 0.60% of casein. It is evident, therefore, that, if 
gravity cream is used, it is impossible to get less than 0.60% of 
casein in the mixture with 3% of fat, or less than 0.80 of casein 
with 4% of fat. The percentage of whey protein in the mixture is 
really somewhat higher and that of the casein somewhat lower 
than has been calculated, because about one-quarter of the protein 
furnished by the cream is in the form of whey protein. It is not 
necessary for every-day work, however, to take these small differ- 
ences into consideration. 

Higher percentages of whey protein and lower percentages of 
casein can be obtained with given percentages of fat, if creams 



AND INFANT FEEDING 225 

containing higher percentages of fat are used. It is possible, for 
example, even in the home, to get cream containing 24% of fat by 
taking only the top two ounces off of the quart. 

It is also possible to have any percentage of casein desired with a 
given percentage of fat by using skimmed milk in the mixture. 
The amount of whey protein which can be put in the mixture is, 
of course, correspondingly diminished. When it is desired to work 
off of a whey mixture on to an ordinary mixture without increasing 
the total amount of protein, it is best done by gradually replacing 
the whey by skimmed milk and water. One ounce of skimmed 
milk and three ounces of water contains approximately the same 
amount of protein as four ounces of whey. 

Preparation of Whey. — Put a pint of skimmed milk into a 
clean saucepan and heat it until it is lukewarm (not over 100° F.). 
Take off of the stove. Add two teaspoonfuls of essence of pepsin 
or liquid rennet, or two junket tablets. Stir just enough to mix. 
Let it stand until firmly jellied. Then break up with a fork until it 
is finely divided. Strain through a linen cloth or several thick- 
nesses of cheesecloth. What goes through is whey. If whey is to 
be mixed with cream, milk or skimmed milk, it must be brought to 
150° F. in order to kill the rennin. If whey is not brought to this 
temperature before it is added to milk or cream, the rennin in it 
will curdle them. It should be cooled before being mixed with 
cream or milk. 

The Determination of Percentages in Mixtures. — It is often 
of great importance to find out just what a baby has been taking 
in order to know how to change the food, if it is not agreeing with 
it. To do this it is necessary to determine the percentages of the 
different elements in the food. This is not a difficult matter. 
Suppose that a baby is taking a food made up as follows: 

Gravity cream 12 ounces 

Skimmed milk 18 ounces 

Lime water 6 ounces 

Barley water 12 ounces 

Milk sugar 4 rounded tablespoonfuls 

The barley water is made with two teaspoonfuls of barley flour 
in a pint of water. 

The total quantity of the mixture is forty-eight ounces. Gravity 
cream contains 16% of fat. Twelve ounces of gravity cream in a 
forty-eight-ounce mixture will give, therefore, 12/48 of 16% of fat, 
or 4% of fat. Both gravity cream and skimmed milk contain 
3.20% of protein. There are thirty ounces of gravity cream and 



226 DISEASES OF NUTRITION 

skimmed milk in the mixture. Thirty ounces in a forty-eight- 
ounce mixture will give 30/48 of 3.20% of protein, or 2.00% of 
protein. Both the gravity cream and the skimmed milk also 
contain 4.50% of sugar. Thirty ounces of gravity cream and 
skimmed milk in a forty-eight-ounce mixture will, therefore, fur- 
nish 30/48 of 43/2, which is the same as 30/48 of 9/2, or almost 
3.00% of milk sugar. Four rounded tablespoonfuls of milk sugar 
are equal to two ounces. Two ounces of sugar in a forty-eight- 
ounce mixture is equal to 2/48 of 100%, or 4%. The total per- 
centage of sugar is, therefore, 7%. Two teaspoonfuls of barley 
flour in a pint of water makes a 1.50% decoction of starch. Twelve 
ounces of barley water of this strength in a forty-eight-ounce mix- 
ture will give 12/48 of 1.50% or about 0.35% of starch. There are 
six ounces of lime water in the mixture and thirty ounces of gravity 
cream and skimmed milk; 6/30 of 100% is 20%. The lime water 
in the mixture is, therefore, 20% of the milk and cream. The 
mixture thus contains 4% of fat, 7% of milk sugar, 2% of protein 
and 0.35% of starch, while the lime water is present in the propor- 
tion of 20% of the cream and milk. 

Method of Determining the Caloric Value of Mixtures of Modi- 
fied Milk. — The method detailed below is longer than some of 
the other methods in common use. It is more accurate than many 
of them, however, and has this in its favor, namely, it is impossible 
to carry it out without fully understanding what the caloric value 
of food really means. 

Suppose that a baby is taking thirty ounces of a food containing 
4% of fat, 6% of sugar, 2.25% of protein and 0.75% of starch. 
Thirty ounces is equal to 900 cubic centimeters. Four per cent fat 
means that there are 4 grams of fat in each 100 cubic centimeters 
of food. The baby is taking 900 cubic centimeters of food, 
that is, it is taking nine times the amount of fat in 100 cubic centi- 
meters of food, or nine times 4 grams, which is 36 grams. The 
caloric value of 1 gram of fat is 9.3 calories. Thirty-six grams 
of fat will give thirty-six times 9.3 calories, which is equal to 
334.8 calories. 

The caloric value of sugar, starch and protein is the same, each 
gram yielding 4.1 calories. 1 The caloric value of these elements 
can, therefore, be calculated at the same time. There are 6 
grams of sugar, 2.25 grams of protein and 0^75 grams of starch, 
or a total of 9 grams in each 100 cubic centimeters of the food. 
There are, therefore, nine times 9 grams, or 81 grams, in 900 
cubic centimeters of food. One gram is equivalent to 4.1 calories. 
1 The caloric value of a gram of milk sugar is in reality 3.78 calories. 



AND INFANT FEEDING 227 

Eighty-one grams provide 81 x 4.1 calories or 332.1 calories. The 
sum of the 334.4 calories furnished by the fat and the 332.1 
calories furnished by the sugar, starch and protein is 666.9 
calories, which is, therefore, the caloric value of the mixture. 

The caloric value of the food is of importance only in its relation 
to the weight of the baby. Suppose that the baby who has been 
taking the above food weighs eleven pounds. Dividing the 
number of calories in the food by the weight gives the number of 
calories which it gets per unit of weight. That is, 666.9 calories 
divided by eleven gives 60 calories, which is the number of calories 
which it is getting per pound of weight. 

A kilogram is equal to two and two-tenths pounds. Eleven 
pounds is equal, therefore, to 5 kilograms. Dividing 666.9 calories 
by five gives the number of calories which the baby is getting 
per kilogram of body weight, that is, 133 calories. 

A simple, but less accurate, method of calculating the caloric 
value of a modified milk mixture is that recommended by Fraley 
(Archives of Pediatrics, 1912, xxix, 123). Letting F = the per- 
centage of fat, S the percentage of sugar and starch, P the per- 
centage of protein and Q the total quantity of food, then 

2F + P + SxlMQ = calories. 

This formula always gives the caloric value a little lower than it 
really is. It gives, for example, 637 calories as the value of the 
food just calculated above, when the real value is 666.9 calories. 

Still another method, which is also accurate, is that recom- 
mended by Bowditch (Jour. A. M. A., 1909, liii, 1265). The caloric 
value of a food is very easily calculated by this method by the use 
of a table. 

The Method of Determining the Protein Content of Mixtures 
of Modified Milk. — It is very easy to determine the protein con- 
tent of a food by using the same principle employed in estimating 
the caloric value. Suppose that a baby weighing fifteen pounds is 
taking forty-eight ounces of a food containing 2.50% of protein. 
Forty-eight ounces is equal to 1440 c. c. There are 2.5 grams of 
protein in each 100 c. c. of food, or 14.4 x 2.5 grams in the 
whole amount. 14.4 x 2.5 grams = 36 grams. The baby weighs 
fifteen pounds. It gets, therefore, 2.4 grams of protein per pound 
of body weight in this food. Fifteen pounds is 6.8 kilograms. 
Dividing 36 grams by 6.8 gives 5.3 grams, which is the amount of 
protein which the baby gets per kilogram of weight from this food. 

The Pancreatization of Modified Milk. — Pancreatized milk 
prepared with "Peptogenic Milk Powder" is often given to in- 



228 DISEASES OF NUTRITION 

fants. The objection to the use of pancreatized milk prepared in 
this way is that, if the directions as to the preparation of the food 
are followed, it is a routine food and not susceptible of variation to 
meet the needs of the individual infant at the given time. It is 
far better to make a mixture to meet the indications in the given 
case and then to pancreatize it by the addition of one of the 
" peptonizing " powders or tablets. In this way the advantages of a 
food suited to the needs of the baby and of predigestion of the 
food are both retained. 

The food may be heated at " blood heat," not over 115° F., for 
ten minutes and then brought quickly to a boil. The ferments are 
destroyed by the boiling and the food will, therefore, not become 
bitter. It is better to add a part of the contents of a " peptonizing " 
tube or part of a tablet to each feeding just before it is to be used. 
The feeding is then heated for from ten minutes to fifteen minutes 
at blood heat, or from 100° F. to 115° F., being allowed to drop to 
100° F. toward the end of this time, and immediately given to the 
baby. The advantage of this method is that the ferments are 
still active when the food is ingested and will continue to act until 
the reaction of the stomach contents becomes acid. The contents 
of a "peptonizing" tube, or a " peptonizing " tablet, are usually 
intended for the pancreatization of a pint of milk. The proportion 
of milk in each feeding being known, it is a simple matter to 
calculate how much of the powder or tablet to add. " Peptonized 
milk" prepared by the so-called "cold process" is, of course, not 
predigested at all, because the pancreatic enzymes do not act in the 
cold. The only opportunity which they have to act, when milk is 
prepared by this process, is after they are taken into the stomach. 
Their action ceases, however, when the reaction of the stomach 
contents becomes acid. 

PROPRIETARY FOODS 

The first thing to be remembered when considering the propri- 
etary foods is that there are only certain food elements, namely, fat, 
carbohydrates, protein and mineral matters. There can, therefore, 
be nothing in the proprietary foods except these elements. All of 
the elements are easy to procure and can be put into modified milk 
in any form and in any amount desired. 

It is often said that a certain baby did not do well on modified 
milk but at once began to thrive when given a certain propri- 
etary food. Such a statement is undoubtedly true. This does not 
show, however, that this proprietary food is better than modified 



AND INFANT FEEDING 229 

milk. It merely shows that the combination of the different food 
elements in this food was the one suitable for this baby. There was 
nothing in the proprietary food which could not have equally well 
been put in a modified milk. The difficulty with modified milk was 
that the person who prescribed it did not understand or know how 
to meet the indications in the given case. If he had, the baby 
would have thrived as well on modified milk as on the proprietary 
food. It is noteworthy in this connection that while much is said 
in praise of a given food when a baby does well on it, nothing is 
said about all the other proprietary foods upon which it did not do 
well. 

A great objection to proprietary foods is that their use tends to 
develop slip-shod methods on the part of physicians. They get in 
the habit of choosing proprietary foods at random or of using some 
food constantly, because they have seen a number of babies thrive 
on it, instead of thinking for themselves and endeavoring to pre- 
scribe a milk modification to fit the needs of the individual baby at 
the given time. Another objection to the proprietary foods is 
that, being led by the advertisements of the manufacturers of 
these foods to believe that the artificial feeding of infants is a 
very simple matter, parents attempt to feed their own babies on 
such foods instead of employing a physician to prescribe the feed- 
ing. The results are often unfortunate, to say the least. 

A still further objection to proprietary foods is their cost. It is 
a self-evident proposition that the people who buy the foods have 
to pay for the manufacture and advertising of the food, as well as a 
profit to the manufacturer and various middlemen, neither the 
manufacturer nor the middlemen being in business "for their 
health." This expense is unnecessary, because modifications of 
milk containing everything which is in these proprietary foods can 
be readily prepared from simple materials in the home. The 
composition of some of the proprietary foods in most common 
use in this country is given in the table on pages 230-231. 

It is noteworthy that these proprietary foods can be divided into 
four main groups. I. The condensed milks, sweetened or un- 
sweetened. II. The malted foods, in which the whole, or a con- 
siderable part, of the carbohydrates is in the form of maltose and 
the various dextrins. III. The foods in which there is a con- 
siderable proportion of starch in addition to the soluble carbohy- 
drates. IV. The foods which are almost entirely composed of 
starch. The different groups are worthy of separate consideration. 

I. The Condensed Milks. — Condensed milk is almost never 
given undiluted. The customary dilution is one part of con- 



230 



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232 DISEASES OF NUTRITION 

densed milk to nine parts of water. This dilution gives a mixture, 
if Eagle Brand Condensed Milk is used, containing 0.96% of fat, 
5.49% of sugar and 0.80% of protein. This analysis explains why 
a baby that has a disturbance of digestion from overfeeding will 
do well on condensed milk. It will do equally well on a modified 
fresh milk containing the same percentages. It is also evident, 
from this analysis, that a very large amount of this food must be 
taken to cover the caloric and protein needs of a baby. The rela- 
tion between the carbohydrates and fat is not a proper one for the 
normal well infant and the protein is too low. The caloric value of 
the food is even lower, when the unsweetened condensed milks are 
used. Condensed milk is, moreover, not a uniformly sterile prod- 
uct, as is commonly supposed. Some specimens are sterile, but 
many are not. The bacterial content of some of them is as high as 
10,000,000 per cubic centimeter. 1 

II. The Malted Foods.— Horlick's Malted Milk and Mellin's 
Food are examples of this class. The chief reasons that foods of 
this class agree with so many babies are that the carbohydrates are 
in the form of maltose and dextrins and that the dextrins, by their 
colloidal action, favor the digestion of protein. When mixed with 
water, the mixtures are deficient, in that the fat and protein con- 
tent is too low. When mixed with milk or cream, the result is a 
modified milk with the sugar in the form of maltose and the dex- 
trins. It is far better to modify the milk to fit the need of the 
individual infant than to use one of these foods, as all the ad- 
vantages of these foods can be obtained and the disadvantages 
avoided by the use of one of the dextrin-maltose mixtures instead of 
milk sugar, or by the dextrinizing of a cereal gruel. 

III. The Sugary and Starchy Foods. — Examples of the foods 
which contain considerable amounts of starch in addition to 
various combinations of the various sugars are Eskay's Albumi- 
nized Food, Nestle's Food and "Allenburys" Food No. 3. The 
fat content of the foods of this class is, as a rule, almost infinites- 
imal. When diluted with water they amount to but little more 
than a starch and sugar mixture. When mixed with some form 
of milk they correspond to a modified milk prepared with a cereal 
diluent. 

IV. The Starchy Foods. — Imperial Granum and Ridge's Food 
are striking examples of the starchy foods, or rather of the starch 
foods. The composition of these two foods is almost identical. 
The following comparison of the analyses of Imperial Granum and 
ordinary wheat flour is interesting and instructive. (Table 48) 

1 Jordan and Mott: American Journal of Public Hygiene, 1910, xx, 391. 



AND INFANT FEEDING 

TABLE 48 



233 



Imperial Granum 1 
Wheat flour 2 



Fat 



1.04 
1.00 



Sugar 



■• ™f dextrose 0.42 



[dextrins 1.38 



0.00 



Protein 



14.00 
11.40 



Starch 



73.54 

75.10 (total 
carbohy- 
drates) 



Ash 

0.39 
0.50 



It is evident that the sum of the sugars and starch in Imperial 
Granum is essentially the same as the total carbohydrate content 
of wheat flour. Heating wheat flour will change a small per- 
centage of the starch into dextrin and dextrose. It would seem 
cheaper for people to bake their own flour than to pay someone 
else to do it for them, even if they do put it up in a box and give it 
another name. 



THE FEEDING OF INFANTS AFTER WEANING AND DURING THE 
SECOND YEAR 

The average baby that has done well, whether it has been fed on 
the breast or artificially, will be taking, when it is about ten 
months old, a mixture of whole milk and barley water. It will be 
taking five feedings at three-hour intervals, beginning at six in the 
morning and ending at six at night. If it has shown a tendency to 
constipation, it will probably be taking some orange juice. 

It may be remarked here, parenthetically, that orange juice is 
not a necessary part of a baby's diet, as many people suppose. It is 
advisable to give it, if the food is pasteurized or boiled, in order to 
guard against the possible development of scurvy. It is also useful, 
if there is a tendency to constipation. It will, moreover, sometimes 
restore a failing appetite. In such cases, however, it is probable 
that the loss of appetite is an early symptom of scurvy. It is wiser 
to give it for definite indications than to use it as a routine measure, 
although it probably does no harm in most instances, even if it is 
not indicated. The best time to give orange juice is one hour 
before a feeding, when the stomach is comparatively empty. It is 
less likely to disturb the digestion when given at this time. It is 
rarely advisable to give more than two tablespoonfuls to a young 

1 Analysis given by Holt. Diseases of Infancy and Childhood, 1911, p. 162. 

2 Chemical Composition of American Food Materials. Atwater and Bryant. 
Bulletin No. 28, U. S. Department of Agriculture. 



234 DISEASES OF NUTRITION 

baby. The whole amount for the day should be given at one time. 
It may be diluted with water and sweetened with cane sugar if 
desired. 

The simple cereals should be begun about this time. The most 
easily digestible are barley jelly, oat jelly and farina. The barley 
jelly is made from barley flour, the oat jelly from oat flour or oat- 
meal thoroughly cooked and strained. Two or three rounded 
tablespoonfuls of flour to a pint of water will make a jelly. It 
should be cooked at least an hour. When oatmeal is used it should 
be cooked at least four hours. All cereals which are given to 
infants and children must be thoroughly cooked. Even the simple 
ones should be cooked several hours, in spite of the fact that the 
directions on the package may state that fifteen to twenty minutes 
is sufficient. The most satisfactory way of cooking them is in a 
"fireless cooker.". 

In beginning to feed cereals, they should be given at the begin- 
ning of the 9 A. M. and 6 P. M. feedings. Some of the baby's 
mixture should be put on them, never cream or top milk. They 
should be salted, but no sugar should be used. If babies begin to 
eat cereals without sugar, they learn to like them in that way and, 
as they grow older, do not expect to have them or other foods 
smothered in sugar. The chances of the development of a sugar 
indigestion in the future are thus much diminished. It is well to 
begin with a level tablespoonful of cereal, increasing the amount as 
necessary. 

It is usually wiser to wait a few weeks after beginning to give 
cereals, before giving beef juice or broth. The most satisfactory 
form of beef juice is the freshly prepared beef juice. This is made 
by half-broiling a piece of round steak. The steak should then be 
cut into small pieces and the juice squeezed out with a beef press 
or a lemon squeezer. Beef juice prepared in this way contains 
about 0.60% of fat and 2.90% of protein, with a considerable 
amount of extractive matters. Dish gravy, as it is called, is not 
the same thing. It contains a large amount of cooked fat and is 
often highly indigestible. The various manufactured beef juices, 
meat extracts and similar preparations are not as good as the ex- 
pressed beef juice and should be used only when it is impossible to 
obtain fresh beef juice. 1 Beef juice may be given plain or diluted 
with water. It should be salted to taste. It is wiser to begin 
with one teaspoonful, gradually increasing the amount to six 

1 See Bull. No. 114, Bureau of Chemistry, U. S. Dept. of Agriculture, 
"Meat Extracts and Similar Preparations," and Jour. A. M. A., 1909, liii, 
1754, "Meat and Beef Juices." 



AND INFANT FEEDING 235 

teaspoonfuls, or one ounce. Babies should never be given more 
than two ounces of beef juice, even in their second year. Beef juice 
is liable to disturb the digestion of some babies and not infrequently 
makes other babies nervous and sleepless. It is always well, there- 
fore, to warn mothers of this possibility when beef juice is first 
given. The best time to give beef juice is at the beginning of 
the noon feeding. 

Mutton broth and chicken broth must be very carefully pre- 
pared. The fat must be entirely skimmed off and the broth should 
be thick enough to form a jelly when cold. Two ounces should 
be given in the beginning and this amount increased to four ounces 
later. The broth should also be given at the beginning of the noon 
feeding, beef juice being given one day, broth the next, and so on. 
It must be remembered that the nutritive value of broth is prac- 
tically nil. The broth serves merely as a vehicle for other food and 
as a stimulant to the appetite. 

It is well to begin to give breadcrumbs and zwiebach in the broth 
and beef juice in the course of a few weeks. At the same time the 
baby may be given bread or zwiebach "in its hand" in order that 
it may learn how to eat. 

It is usually possible to leave out the cereal diluent when the 
baby is a year old and give plain milk. In many instances, how- 
ever, it is advisable to continue to give an ounce of barley jelly or 
oat jelly in each feeding until the baby is one and one-half years 
old. The variety of cereals may be increased by the addition of 
Cream of Wheat, Ralston and rice when the baby is a year old. 
At about fourteen months it may have milk toast and bread and 
milk. If desired, a part of the milk may be given in the form of 
junket. If the baby is constipated, prune juice and pulp and the 
inside of baked apples may be added at this time or even earlier. 
Plain white crackers, such as soda crackers, Uneeda Biscuits or 
pilot wafers may also be given, either plain or in the form of cracker 
toast. 

It is wiser, in general, not to begin to give eggs until babies are 
about eighteen months old. Many infants are poisoned by eggs. 
It is always advisable, therefore, to begin eggs very cautiously. 
Eggs should be given at first either soft boiled for about two min- 
utes, or coddled for about four minutes. If eggs do not disagree, 
the baby may be given an egg every other day, and by the time 
it is two years old, an egg daily. This may be given in the morning 
or at noon in place of the broth and beef juice. At one and one- 
half years, baked potato, plain boiled macaroni, rice and Wheat 
Germ may be given. Baked custard, plain blanc mange and plain 



236 DISEASES OF NUTRITION 

boiled tapioca may also be given as desserts, if desired. There is 
no objection at this time to putting butter on the bread. 

This dietary is sufficient until the baby is nearly two years old, 
when meat may be begun. The most easily digestible forms of 
meat are the white meat of chicken, mutton and lamb chop and 
scraped beef. A reasonable dietary for a baby of two years is whole 
milk, butter, mutton broth, chicken broth, beef juice, soft boiled 
eggs, coddled eggs, dropped eggs, white meat of chicken, lamb 
chop, mutton chop, scraped beef, French bread, stale bread, 
toasted bread, whole wheat bread, milk toast, zwiebach, plain white 
crackers, plain Educator crackers, barley jelly, oatmeal, Cream of 
Wheat, Wheat Germ, Ralston, farina, rice, baked potato, plain 
boiled macaroni, orange juice, baked apples, stewed prune pulp 
and juice, junket, baked custard, corn starch pudding, plain blanc 
mange, plain tapioca. It is not advisable, as a rule, to begin green 
vegetables until the baby is two and a half years old. 

In most instances the hours of feeding are changed when the 
baby is from sixteen to eighteen months old. At that time the 
baby gets some milk when it wakes up in the morning. It has its 
breakfast between 8 and 8.30. It gets some more milk, or some 
milk with a piece of bread or a cracker, at 11 or 11.30, before its 
nap. It has its dinner when it wakes up from its nap at 1.30 or 2, 
and its supper at 5.30. 



AND INFANT FEEDING 237 



CHAPTER XIX 
THE FEEDING OF PREMATURE INFANTS 

All the functions of digestion of premature infants are feeble. 
In a general way, the younger the baby, the feebler are the digest- 
ive powers. Little is known positively as to the absolute or rel- 
ative strength of the various digestive ferments in the premature. 
It is probable, however, that the tolerance for sugar is greater than 
that for fat and protein. The amylolitic function may be present 
at birth, but is relatively undeveloped and should not be called 
upon. It is presumable that the metabolic processes are less active 
in the premature than in the full-term baby and that the utilization 
of the food ingested is, therefore, less complete. There is, however, 
no proof of this supposition. It is a well-known fact that small 
bodies have a greater surface area in proportion to their mass than 
have large bodies. The loss of heat is, therefore, relatively greater 
in proportion to the weight in small than in large bodies. A pre- 
mature infant would, therefore, be expected to require more nour- 
ishment in proportion to its weight than would the full-term infant. 
Another, and perhaps more important, reason why premature 
infants lose heat more rapidly than full-term infants is that they 
have very little fat tissue to act as a blanket to keep the heat in. 
They have, moreover, relatively more " active" tissue, *. e., muscle, 
than full-term infants and it is apparently the active tissue which 
uses up energy and not the fat, which is inactive. The difficulties 
in the way of the successful feeding of premature infants are, 
therefore, obvious. 

All the reasons which prove that human milk is the best food for 
the full-term infant are doubly applicable in the case of the pre- 
mature infant. A premature infant should, therefore, always be 
given breast-milk, if it can possibly be obtained. None but the 
strongest infants or those but little premature should, however, 
be put to the breast. The vast majority of them are too feeble to 
nurse satisfactorily and are unable to bear the handling and expo- 
sure consequent on being put to the breast. Many a premature 
infant has had what few chances it had of survival destroyed in 
this way. The milk should be taken from the breast and fed to 
the baby. There is some difference of opinion as to whether it is 



238 DISEASES OF NUTRITION 

better for the newly-born premature baby to have colostrum or an 
established breast-milk. The evidence on the two sides is incom- 
plete, and the question must be considered as still a mooted one. 
In most instances the baby will naturally get its own mother's 
milk, that is colostrum, while if it gets another woman's milk, it 
will usually be an established one. For practical purposes, either 
will do. 

There is also considerable difference of opinion as to whether 
a premature baby should be fed within a few hours after birth, or 
whether it should not be fed for twelve hours or for twenty-four 
hours. Those who believe that it should be fed very soon argue 
that it needs nourishment at once, because of its prematurity and 
feebleness, while those who believe in waiting argue that Nature 
shows that a full-term baby should not have food for from twenty- 
four hours to forty-eight hours, since it does not provide food until 
this time, that the premature baby needs rest after the fatigue of 
labor more than does the full-term baby, and that it is even less 
able to digest food in the first few hours than the full-term baby. 
On the whole, it is probably best to begin to feed the premature 
infant when it is about twelve hours old. 

There is also much difference of opinion as to the intervals at 
which premature babies should be fed. It used to be thought that, 
on account of the small amount taken at a feeding and the greater 
need for food, they should be fed every hour or every one and one- 
half hours. Such frequent feedings do not give the stomach a 
chance to empty itself, however, and do not give the baby a suffi- 
cient opportunity for continued sleep. Ten feedings at intervals of 
two hours during the day and of four hours during the night meet 
the indications better. The stomach then has time to empty itself 
and the baby is not disturbed too often. Czerny and Keller * have 
for a long time advocated four-hour intervals, and Litzenberg 2 
has recently reported some extremely good results in a series of 
fifty cases fed at these intervals. His results show, if nothing more, 
that premature babies can thrive on these longer intervals. An 
additional advantage in these intervals is that if babies do thrive 
as well on them as on the shorter intervals, the care and attendance 
required are much less. 

Caloric Needs. — The reason why the caloric needs of a pre- 
mature baby would be expected to be greater than those of a full- 
term baby have already been mentioned. Experience has shown, 
moreover, that, on the average, premature babies that are thriving 

1 "Ernahrung des gesunden Kindes," p. 685. Quoted by Litzenberg. 

2 Amer. Journal of Diseases of Children, 1912, iv, 391. 



AND INFANT FEEDING 239 

do take and require more calories per Kilo of body weight than do 
full-term babies. 1 The average quotient is, however, not as high as 
was formerly supposed. Most premature babies need about 120 
calories per Kilo, but there are many exceptions. Some premature 
babies will thrive and gain on as little as 70 calories per Kilo. No 
attempt should be made to reach 120 calories per Kilo during the 
first few days. Thirty calories per Kilo is as much as it is wise to 
give in the first twenty-four hours of feeding. This amount 
should be gradually increased each day, watching carefully for 
symptoms of indigestion, and diminishing it if these appear. In 
most instances, 120 calories per Kilo can be given in about ten 
days. Very few are able to utilize more than 130 calories per Kilo. 
If this amount is exceeded, they are, in most instances, upset. 
Character of Food. — The first food given should be breast- 
milk diluted with an equal amount of water or a 3% solution of 
milk sugar. The dilution should be diminished from day to day. 
In most instances undiluted breast-milk can be given in from four 
days to a week. If it is impossible to obtain breast-milk, the best 
substitute is modified cow's milk. It is very important to begin 
with very weak mixtures in order not to upset the digestion in the 
beginning. It is very easy to kill a premature baby or to disturb 
its digestion so much that a long time is required to remedy it by 
giving too strong a mixture in the beginning. On the other hand, 
it is very easy to strengthen the mixture, if the baby is not satis- 
fied. It is never a mistake to give too weak a mixture; always a 
mistake to give a strong one. Whey mixtures are better than 
ordinary mixtures, because the protein is in a more easily digestible 
form and hence throws less work on the feeble digestive organs. 
The following mixtures are suitable ones : 

Fat 1.00% 

Milk sugar 4.00% 

Total proteins 0.25% 

Lime water 25% of the cream and milk in the mixture. 

Fat 1.00% 

Milk sugar 4.50 % 

Total proteins 0.50% 

Lime water 25% of the cream and milk in the mixture. 

It is wiser to spirt the protein in these mixtures, making the 
whey protein and the casein the same. The mixture should be 

1 Morse: Amer. Jour, of Obstetrics, 1905, li, 589; Rott: Zeitschr. f. Kinder- 
heilk, 1913, v, 134; Hess: Amer. Jour. Diseases of Children, 1911, ii, 302; 
Zahorsky: Baby Incubators, 1905. 



240 DISEASES OF NUTRITION 

gradually strengthened to cover the caloric needs, due attention 
being paid to the condition of the stools in deciding which element 
or elements to strengthen. 

Amount of Food. — Whether the food is breast-milk or modified 
milk, it is better to begin by giving one drachm (5 c. c.) at a 
feeding. If the baby is not satisfied, it is very easy to gradually 
increase the amount. It should be increased every day or every 
few feedings, if necessary. No harm can be done in giving too 
little at first; irreparable harm may be done by giving too much. 

Finally, always begin to feed premature babies with small 
amounts of a very weak food and increase the strength and amount 
at a feeding as rapidly as the individual baby's digestion will allow, 
bearing in mind that it is less dangerous to give too small amounts 
and too weak a food than to give too large amounts and too strong 
a food. If a premature baby's digestion is disturbed, it is not safe 
to give a cathartic freely and starve it. Like atrophic babies, they 
cannot bear starvation, but must be fed. 

Water. — Premature babies, because of the high temperature 
and dryness of the air by which they are surrounded, need a con- 
siderable amount of water. It is estimated that the daily ingestion 
of liquid should be one-sixth of the body weight. 

Methods of Feeding. — It is seldom advisable to put a premature 
baby to the breast, because it is usually too feeble to nurse well 
and because the handling and exposure consequent on being put 
to the breast overtax the vitality too severely. When the infant 
is strong enough to take food from a nipple, it should be fed from 
the bottle. Many babies are not strong enough to do this, how- 
ever, and have to be fed in some other way. The most satisfactory 
way to feed such babies is with the Breck feeder. This consists 
essentially of a graduated glass tube, open at both ends. On the 
smaller end is a nipple about the size of the rubber of a medicine 
dropper. This is perforated and goes into the baby's mouth. On 
the other end is a large rubber finger-cot. By squeezing the 
finger-cot, milk is forced into the baby's mouth and efforts at 
sucking aided or induced. Some babies are too feeble to take food 
even in this way, and have to be fed with a medicine dropper. If a 
baby does not take its food well by any of these methods, there is 
no objection to feeding it with a tube. In fact, it often saps the 
baby's vitality less to be fed in this way than in any other. The 
passage of the tube seldom causes much strangling and vomiting, 
as the pharyngeal reflex is, in most instances, not fully developed. 
The tube should be passed through the mouth, not through the 
nose. A No. 9 or No. 10 catheter is suitable. It should be passed 



AND INFANT FEEDING 241 

in about fifteen centimeters, the distance from the gums to the 
cardia in full-term babies being seventeen centimeters (6% inches) 
and less in the premature infant. If the baby is fed with the tube it 
is better not to give it more than eight feedings a day, fewer, if 
possible. 



SECTION IV 

DISEASES OF THE GASTROINTESTINAL 
CANAL 

CHAPTER XX 

SPASM OF THE PYLORUS 

Spasm of the pylorus is more common in infancy than is hyper- 
trophic stenosis. It is often a complication of stenosis and is not 
infrequently mistaken for it. In fact, it is probable that a very 
large majority of the cases of pyloric stenosis which have been 
reported as cured by medical treatment were not really cases of 
organic stenosis but of spasm. 

ETIOLOGY 

The etiology of spasm of the pylorus in infancy is very obscure. 
It apparently occurs most commonly in excitable and nervous 
infants, the offspring of neurotic parents. Some writers believe 
that the normal muscular hyperirritability at this age predisposes 
to pyloric spasm and that the mechanical irritation of the food or 
the chemical products of digestion thus directly or reflexly cause 
spasm when they would not in later life. Others believe that 
disturbance of the gastric digestion always precedes and causes the 
spasm. However this may be, it is certain that spasm of the 
pylorus occurs much more frequently in artificially-fed than in 
breast-fed babies. A hypersecretion of gastric juice has been found 
in some cases and hyperacidity of the gastric juice in others. The 
favorable results in many cases of treatment intended to neutralize 
hyperacidity make it seem probable that this is one of the causes, at 
least, of this condition. How large a proportion of the cases is due 

to this cause is uncertain. 

< 

SYMPTOMATOLOGY 

In the first place, the baby is usually of the excitable, irritable 
and neurotic type. It is much more often artificially-fed than 
breast-fed. The first symptom is vomiting. It may appear imme- 

243 



244 DISEASES OF NUTRITION 

diately after birth, but usually does not develop for several weeks 
and sometimes not until the baby is several months old. In the 
milder cases this is the only symptom. It is, however, often pre- 
ceded and accompanied by evidences of gastric pain and distress. 
The vomiting is at times explosive and at others not. The amount 
of the vomitus does not ordinarily exceed the amount of food 
taken at the last meal. The vomitus shows, as a rule, little or no 
evidences of disturbance of the digestion. There is a tendency to 
constipation, but the stools show plainly that a considerable 
proportion of the food ingested passes through the pylorus into the 
intestine. The disturbance of nutrition is not extreme. 

In the more severe cases there is visible peristalsis in addition 
to the symptoms already given as characteristic of the milder 
type. These symptoms are more marked than in the mild cases, 
the stools show less fecal residue and the disturbance of nutrition is 
much greater. In the most severe cases there is also a palpable 
tumor at the pylorus. This tumor is usually small in comparison 
with that felt in hypertrophic stenosis of the pylorus. It feels 
longer and thinner. In typical cases it can be felt to appear and 
disappear under the finger as the pylorus contracts and relaxes, in 
contradistinction to the tumor in hypertrophic stenosis which does 
not change. 

Roentgenograms, taken after a bismuth meal, show very marked 
interference with the passage of the stomach contents into the 
duodenum. They seldom show, however, such complete and 
permanent obstruction at the pylorus as is commonly present in 
hypertrophic stenosis. 

DIAGNOSIS 

The differential diagnosis between spasm and hypertrophic 
stenosis of the pylorus has already been described in the discussion 
of the latter condition. The points of the greatest value in diagnos- 
ing spasm of the pylorus from indigestion with vomiting are the 
absence of evidences of indigestion in the vomitus, the explosive, 
projectile vomiting, the presence of visible peristalsis and of a 
palpable tumor, and the delay in the opening of the pylorus, shown 
in Roentgenograms taken after a bismuth meal. On habitual 
vomiting, the other condition with which spasm of the pylorus may 
be confused, the general condition of the baby is unaffected, the 
vomiting varies with the position and activity of the baby and is 
never projectile, the stools are sufficient in amount and fecal in 
character, there is no visible peristalsis and, of course, no palpable 
tumor. 



AND INFANT FEEDING 245 



PKOGNOSIS 

The prognosis is, in general, good. The symptoms persist for 
many weeks or months in the severe cases, however, even under 
the most careful treatment. Some of the most severe cases are not 
amenable to medical treatment and will die unless operated upon. 

TREATMENT 

The most important part of the treatment of pyloric spasm is 
regulation of the diet. The best food is good human milk. If this 
is vomited, it is well to remove a part of the cream and add lime 
water. The next best food is some modification of cow's milk. 
It is advisable to keep the percentage of fat low, because fat tends 
to delay the emptying of the stomach. A percentage of 0.50 is 
none too low in the beginning. It is also advisable to give as large 
a proportion as possible of the protein in the form of the whey pro- 
teins, because they are not coagulated by rennin and, therefore, 
easily pass the pylorus. Plain whey is very useful in some in- 
stances. All the measures which prevent the formation of large 
casein curds are applicable in this condition, in that they make the 
emptying of the stomach less difficult. Carbohydrates, which leave 
the stomach readily and quickly, can usually be given freely. 
Lactose is the best of the sugars in this condition. These general 
principles serve, of course, only as a basis for the preparation of 
the food, which must be varied to suit the individual baby. 

Clinically, the addition of an alkali to the food is of considerable 
assistance in many of these cases, while in others it apparently does 
no good. It presumably does good by delaying the coagulation of 
the casein by rennin and thus favoring the passage of the liquid 
milk through the pylorus. It should be added in relation to the 
milk and cream in the mixture, not in relation to the total quantity 
or to the whey in the mixture. It is well to add lime water at first 
to the amount of fifty per cent of the milk and cream. If some 
other alkali is used, a corresponding amount should be given. 
Cowie 1 believes that the action of the alkali is dependent on the 
degree of the acidity of the gastric contents and the effect of the 
change of the reaction of the gastric contents on the pyloric reflex. 
If his explanation is correct, it is possible to exaggerate the condi- 
tion by giving alkalis, and in any case the alkalis must be added 
very carefully, preferably on the basis of the findings obtained by 
the analysis of the gastric acidity. 

There is much difference of opinion as to whether the food should 
1 American Journal of Diseases of Children, 1913, v, 225. 



246 DISEASES OF NUTRITION 

be given at short or long intervals and as to the quantity which 
should be given at a feeding. The most rational way of regulating 
the interval between feedings is to determine how long it takes the 
stomach to empty itself in the individual case and to make the 
intervals somewhat longer than this. In general, it is probably 
better to give small amounts at a feeding, although there are many 
exceptions to this rule. 

Daily lavage with plain water or a weak solution of bicarbonate 
of soda is of assistance in most cases, although some authors think 
that it tends to keep up the spasm. Warm applications to the 
epigastrium for one-half an hour before and one-half an hour after 
feeding are sometimes of assistance. Flaxseed meal poultices are 
the most efficacious. Minute doses of some preparation of opium — 
£• Q>j ?V of a minim of the tincture — given a short time before 
feeding sometimes seem to diminish the spasm. Atropine and 
cocaine have also been used for the same purpose. It is also im- 
portant to keep these babies very quiet, especially immediately 
after feeding. 

Rosenhaupt l claims good results in this condition from rec- 
tal irrigations of salt solution, basing his treatment on Engel's 
statement that the cause of the trouble in gastrosuccorrhoea and 
on Benczur's experiments which show that in animals rectal 
injections of salt solution diminish the secretion of gastric juice. 
He obtained favorable results in all but one case, but does not 
state how many patients he treated. Rosenstern claims good 
results in four cases from the rectal instillation of from 250 c. c. to 
400 c. c. of Ringer's solution daily. This method of treatment is, 
however, so new that it must be regarded as still sub judice. 

Surgical intervention for the relief of pyloric spasm is. seldom 
necessary. Experience has shown, however, that babies sometimes 
die of this condition under medical treatment. When, therefore, 
a baby is steadily going down hill under medical treatment, sur- 
gical intervention is indicated. An operation will relieve the symp- 
toms and save the baby's life, just as it does in hypertrophic 
stenosis of the pylorus. The spasm will cease in time. When this 
happens and there is no longer any obstruction to the passage of the 
food through the pylorus, the food will then pass through the 
pylorus, the opening from the stomach into the bowel will close 
and the normal conditions be reestablished. 

1 Deutsche med. Woch., 1909, xxxv, 1789. 



AND INFANT FEEDING 247 



CHAPTER XXI 
HYPERTROPHIC STENOSIS OF THE PYLORUS 

The pathological condition in this disease is an overgrowth of 
the circular muscular fibres of the pylorus. The longitudinal fibres 
are little, if at all, involved. The normal longitudinal folds of the 
mucous membrane lining the pylorus are hypertrophied. There is 
at times a slight increase in the connective tissue of the submucosa. 
The opening of the pylorus, which normally admits a No. 21 sound, 
French scale, is narrowed by the thickened muscle and the folds 
of mucous membrane until, in well-marked cases, it will not allow 
the passage of even a fine probe. In extreme cases it is impossible 
to force water through the pyloric opening. The tumor is usually 
about the size and shape of a dressed olive. 

There is more or less hypertrophy of the muscles of the stomach 
wall in all cases. There is also almost always some enlargement 
of the stomach. This enlargement of the stomach may be consid- 
erable in advanced cases. The oesophagus is also sometimes some- 
what dilated. The intestines are collapsed and empty. There are 
no evidences of inflammation and in most instances there is no 
catarrhal condition of the gastric mucosa. There is general wasting 
of all the organs and tissues as the result of starvation. 

The muscular hypertrophy is sufficient after a few weeks, in the 
great majority of instances, to practically occlude the pyloric 
orifice and to almost or entirely prevent the passage of the gastric 
contents into the duodenum. It is probable that in other instances 
the hypertrophy is less marked and the narrowing of the lumen 
consequently less extreme. It is presumable that this hypertrophy 
is at the bottom of some of the cases of pyloric obstruction which 
develop in late childhood and adult life. It is possible that when 
the overgrowth is slight it may be neutralized by the growth of the 
parts with age. The facts that the conditions found at autopsy 
in one instance some months after gastroenterostomy for a com- 
plete obstruction were the same as at the time of the operation 1 
and that Roentgenograms show that the food continues to pass 
through the new stoma for years after the operation indicate, how- 

1 Morse, Murphy and Wohlbach, Boston Medical and Surgical Journal, 
1908, clviii, 480. 



248 DISEASES OF NITRUTION 

ever, that there is no diminution in the hypertrophy in those in- 
stances in which it is marked. 



ETIOLOGY 

The etiology of this condition is obscure and has given rise to 
much discussion. The weight of the evidence, however, is in favor 
of the view that it is a congenital abnormality rather than the 
result of muscular spasm, acting either before or after birth. 
There is no doubt, on the other hand, that in many instances in 
which the stenosis is not complete, the symptoms are exaggerated 
by spasm. 

Hypertrophic stenosis of the pylorus occurs more frequently in 
boys than in girls. It is just as common in breast-fed babies as in 
the artificially-fed. 

SYMPTOMATOLOGY 

The first symptom is vomiting. It may begin in the first few 
days of life, but ordinarily does not appear before the beginning 
of the second week. It seldom develops after the first month. 
There is nothing characteristic about the vomiting in the beginning. 
It soon becomes forcible and explosive. The gastric contents may 
be shot out of the mouth to a distance of several feet. The vomiting 
usually occurs soon after the taking of food, but may occur at any 
time, sometimes not until just before the next feeding. Two, or 
even more feedings, are sometimes retained and expelled together. 
The whole of the stomach contents is usually vomited at one time. 
The vomiting is in most instances not accompanied by pain. The 
vomitus consists in the beginning simply of the food taken, which 
is more or less digested according to the interval which has elapsed 
between its ingestion and the vomiting. Later on it often contains 
mucus, but never, except in the rarest instances, bile. There is 
nothing characteristic about the reaction of the gastric contents. 
The baby is anxious to eat again immediately after it has vomited, 
unless it is temporarily exhausted by the process. In spite of the 
frequent vomiting, the tongue is clean and the breath sweet. 

Constipation quickly develops, because so little of the food passes 
through the pylorus into the intestine that there is but little residue 
to be passed out of the bowels. The stools are small and, being 
composed of the same materials as the meconium, resemble it in 
appearance. 

Loss of weight is a constant symptom. It is progressive and 
becomes more rapid as time goes on. It is due, of course, to the 



AND INFANT FEEDING 249 

lack of food and liquid as the result of the vomiting. The skin 
becomes dry. the face pinched and the baby soon shows all the 
evidences of starvation. 



PHYSICAL EXAMINATION 

The abdomen at first shows nothing abnormal on inspection. 
After a time, however, the epigastrium appears full when food is 
taken, and the rest of the abdomen sunken. When there is dilata- 
tion of the stomach, it may be recognized by inspection and palpa- 
tion. Great care must be exercised in diagnosing dilatation of the 
stomach, however, because of the great variation in the normal 
position of this organ. Waves of peristalsis, running across the 
stomach from left to right, appear soon after the vomiting becomes 
marked. They occur only, of course, when the stomach has some- 
thing in it. If they do not appear soon after food is taken, they can 
often be elicited by stroking the epigastrium, flicking it with a 
towel wet in cold water, or by the application of a piece of ice. 
They are usually about the size of half an egg and run very slowly 
across the epigastrium. Two, or even three, waves are sometimes 
visible at the same time. 

A tumor can be felt in most instances. It is usually situated 
about midway between the tip of the ensiform and the navel and 
between one-half an inch and one inch to the right of the median 
line. This position is, however, not a constant one. The tumor is 
not infrequently under the edge of the liver. It ordinarily feels 
much like a dressed olive, both in size and shape. It does not vary 
in size. It may be mistaken for a large gland. If peristaltic waves 
are present, the tumor will often be found where they disappear. 
The tumor may be felt at any time. It is usually easier to find it 
when the stomach is empty than when it is full, but the opposite is 
sometimes the case. If there is any reason to suspect the presence 
of a pyloric tumor, the abdomen should always be examined with 
the stomach both full and empty. This is easily accomplished by 
having the baby fed or with the aid of a stomach-tube. The 
tumor is most easily felt during the relaxation after vomiting. 
Ether or chloroform should be used to produce relaxation, if neces- 
sary. 

Under normal conditions, Roentgenograms of the stomach, taken 
immediately after a meal containing bismuth, show food passing 
through the pylorus into the duodenum. Roentgenograms taken 
at intervals afterwards show that the stomach is empty in most 
instances in from two to four hours. When there is stenosis of the 



250 DISEASES OF NUTRITION 

pylorus, Roentgenograms taken at once show nothing passing 
through the pylorus. Those taken afterwards show that little or 
nothing passes through the pylorus and show bismuth in the 
stomach for many hours, unless it has been vomited. 

In many instances in which the muscular hypertrophy is not 
extreme, and presumably in most cases in the beginning, the 
narrowing of the pyloric canal which is caused by the mechanical 
obstruction of the tumor is increased by spasm of the muscle. It is 
the spasm of the muscle which accounts for the variation in the 
severity, or even intermittency, of the symptoms in many cases 
and for the sudden onset of severe symptoms in others. When a 
part of the obstruction is due to spasm, everything may be vomited 
for a time and then, when the spasm ceases, a considerable part of 
the food will be retained. The character of the stools will vary at 
the same time, resembling meconium when the spasm is marked 
and being fecal when it diminishes. 

DIAGNOSIS 

The diagnosis of a well-marked case of hypertrophic stenosis of 
the pylorus is very easy. The combination of vomiting, beginning 
within a few days or weeks after birth, increasing steadily in 
severity, becoming projectile in character and having no relation 
to the character of the food, marked constipation with meconium- 
like stools, visible gastric peristalsis and a palpable tumor, not 
varying in size, in the region of the pylorus, is pathognomonic. 
Although the tumor at the pylorus can almost always be found if 
carefully sought for under the proper conditions, a positive diagno- 
sis of this condition is justifiable, if the other symptoms and signs 
are present, even if the tumor cannot be made out. The diagnosis 
should always be confirmed, however, if possible, by Roentgen- 
ograms taken after a bismuth meal. 

The diagnosis between hypertrophic stenosis of the pylorus and 
spasm of the pylorus is, however, at times a very difficult one. The 
onset of the symptoms is the same in both, the vomiting is explosive 
in both and there is visible peristalsis in both. Constipation and 
loss of weight are common to both. There is sometimes a palpable 
tumor in spasm; the tumor is sometimes not palpable in hyper- 
trophic stenosis. In spite of the similarity of the symptoms of the 
two diseases, there should be little difficulty in distinguishing the 
marked cases of hypertrophic stenosis from those of spasm, because 
the constipation is never so marked or persistent in spasm as in 
stenosis and because the tumor in spasm is small and cord-like, not 



AND INFANT FEEDING 251 

large and hard as in hypertrophic stenosis. Variation in the size 
of the tumor during examination is practically positive proof that 
the condition is one of spasm, not of hypertrophy. The difficulty 
in diagnosis comes between the severe cases of spasm and the mild 
cases of hypertrophic stenosis, because the difference in the 
symptomatology of the two diseases is entirely in the degree, not 
in the kind, of the symptoms. 

It is impossible in many instances to make at first a positive 
diagnosis between these two conditions. If the baby is breast-fed, 
the chances are much in favor of hypertrophic stenosis, because 
spasm is very unusual in the breast-fed while hypertrophic stenosis 
is equally common in the breast-fed and in the artificially-fed. If 
the baby is artificially-fed, the chances are even, although if the 
feeding has been very irrational, spasm is a little the more probable. 
The absence of a palpable tumor is strong evidence against hyper- 
trophic stenosis, but does not positively exclude it, because a good- 
sized tumor has sometimes been found at operation when none was 
felt before. It is never safe to conclude that there is no tumor, 
however, unless the abdomen has been examined with the stomach 
both full and empty, and with the abdominal walls relaxed, if 
necessary under an anesthetic. If no tumor is felt under these 
conditions, an almost positive diagnosis of spasm is justified. 
Examination of the gastric contents is of little or no assistance, 
because there are very few reliable data as to the chemistry of the 
gastric contents in these conditions and what few data there are 
are contradictory. An excessive hyperacidity perhaps counts a 
little, however, in favor of spasm. Dilatation of the stomach 
seldom develops in simple spasm of the pylorus and, if it does, is 
always slight. It develops in a certain proportion of the cases of 
hypertrophic stenosis, but is seldom extreme. The presence of 
dilatation is, therefore, in favor of hypertrophic stenosis and against 
spasm. Its absence does not count at all in favor of spasm. Dilata- 
tion of the stomach, unless extreme, is very difficult of demonstra- 
tion in infancy. Too much importance must not be attached, 
therefore, to what are apparently slight degrees of dilatation. 
Rapid improvement under medical treatment and regulation of the 
diet is strong evidence in favor of spasm, but does not positively 
exclude a mild degree of hypertrophic stenosis complicated by 
spasm. The most important points in favor of spasm in doubtful 
cases are, therefore, the absence of a palpable tumor or, if a tumor is 
present, its cord-like feel, the presence of intermittent contraction 
and relaxation of the tumor, and rapid improvement under medicaL 
treatment and regulation of the diet. 



252 DISEASES OF NUTRITION 

Roentgenograms are of less value in the diagnosis between severe 
cases of spasm of the pylorus and mild cases of stenosis than 
between stenosis and other conditions, because there is obstruction 
at the pylorus and therefore delay both in the opening of the 
pylorus and in the emptying of the stomach in both cases. 

When hypertrophic stenosis of the pylorus of slight or moderate 
degree is complicated by spasm of the pylorus, the variation in the 
severity of the symptoms and the temporary response to medical 
treatment and regulation of the diet are often most confusing. 
When there is hypertrophy there is, however, almost always, in 
spite of the variation in the symptoms, a progressive increase in 
their severity. The presence of a tumor which does not change in 
size or shape is conclusive proof that there is an organic stenosis, no 
matter how much the other symptoms may vary. 

The diagnosis between hypertrophic stenosis of the pylorus and 
indigestion with vomiting is a comparatively simple one. Indiges- 
tion seldom occurs in the breast-fed, but develops, as a rule, after a 
longer or shorter period of bad artificial feeding. Vomiting is the 
most prominent symptom, occurs without any definite relation to 
the time of taking food, and is never explosive. The amount of the 
vomitus rarely exceeds that of the food taken at the last feeding and 
the vomitus usually shows evidence of disturbance of the gastric 
digestion. The stools often present the evidences of an associated 
intestinal indigestion, but constipation, as the result of the reduc- 
tion in the amount of food retained, is not uncommon. The stools 
are, however, never of the starvation type, but show by their 
characteristics that food is passing from the stomach into the 
bowel. There is never any visible peristalsis and, of course, no 
tumor to be felt at the pylorus. Roentgenograms taken after a 
bismuth meal will settle the diagnosis at once in doubtful cases, 
because the food begins to leave the stomach immediately in indi- 
gestion, while nothing passes the pylorus for a long time when there 
is obstruction from a pyloric tumor. 

Another condition which sometimes suggests hypertrophic 
stenosis of the pylorus is habitual vomiting. In this condition the 
baby without any other symptoms of indigestion vomits habitually. 
In spite of the vomiting, it nevertheless has stools normal in size 
and appearance and gains steadily in weight. These points are of 
themselves sufficient to rule out stenosis of the pylorus. Further 
points in which the symptomatology of this condition varies from 
that of stenosis are that the vomiting rarely occurs when the baby 
is quiet and that it varies with the amount of exertion and the 
position of the baby. The vomiting is never explosive and there is 



AND INFANT FEEDING 253 

no visible peristalsis or palpable tumor. The vomiting in this 
condition is sometimes due to an excessive amount of food, but 
more often, probably, to the lack of tone or imperfect closure of the 
cardiac orifice. 

PROGNOSIS AND TREATMENT 

The prognosis of hypertrophic stenosis of the pylorus, when the 
obstruction is marked and due wholly or chiefly to the muscular 
hypertrophy, is hopeless under medical treatment. Death will 
surely ensue in a few weeks as the result of starvation. These 
cases can be saved, however, by an operation, provided the opera- 
tion is done at a time when the baby is able to stand the shock of 
the operation, which is a severe one. They should be operated 
upon as soon as the diagnosis is made. Every day of delay mate- 
rially diminishes their chances of recovery. The preferable opera- 
tion is a posterior gastroenterostomy. Another very good opera- 
tion is the modified pyloroplasty recommended by Dr. Keefe. 1 
Both operations require especial skill and should be performed only 
by surgeons who are in the habit of operating on infants or have had 
much experience in operating on small animals. The operative 
mortality is a low one when the operation is performed early and 
the surgeon is competent. 

The medical treatment of these cases both before and after 
operation is of considerable importance. They should be given 
salt solution by enema or seepage, and if necessary subcutaneously, 
before the operation. The stomach should be washed out just 
before the operation. Salt solution should be given in the same 
ways after the operation. Feeding should be begun as soon as the 
baby has thoroughly recovered from the effects of the anesthetic. 
The best food is human milk, diluted at first with three parts of 
water, the strength being quickly increased. If this is not available, 
the next best thing is whey. This should be gradually strengthened 
by the addition of gravity cream to give 0.25% of fat, 0.50% of fat 
and 1.00% of fat. The regulation of the food from this time on is 
usually comparatively simple and along the general lines of infant 
feeding. It is advisable to begin to feed with one drachm (5 c. c.) 
every hour, increasing the amount and lengthening the interval 
between feedings as rapidly as possible. There is very little danger 
of overloading the stomach, because there is no obstacle to the 
passage of the food from the stomach into the intestine. The 
difficulty lies in the intestine, which has not been in the habit of 
receiving large amounts of food. If the intestine is contracted, as it 

1 Boston Med. and Surg. Journal, 1913, chrix, 318. 



254 DISEASES OF NUTRITION 

is in most cases which are operated on late in the disease, it is 
unable to take care of much food. If the operation is performed 
early, before contraction of the intestine has taken place, large 
amounts of food can generally be given. 

The future development of babies successfully operated upon for 
hypertrophic stenosis of the pylorus is normal and their processes of 
digestion and absorption are not impaired. 1 The tumor does 
not diminish in size, the lumen of the pylorus is not restored 
and the food continues to pass through the gastroenterostomy 
opening, when the operation has been a gastroenterostomy. 2 

When the condition is one of partial stenosis complicated by 
spasm, the treatment is primarily that of spasm of the pylorus. 
The methods to be employed are described in the treatment of this 
condition. It is wiser, however, to operate in this condition also, 
unless the symptoms are quickly and almost entirely relieved. 
Unless this is done, the nutrition of the infant is certain to be 
materially impaired and its development retarded. There is but 
little reason to anticipate, moreover, that the organic obstruction 
will diminish in the future. It is also not improbable that a certain 
proportion of the cases of benign obstruction at the pylorus which 
develop in later childhood and early adult life are the result of mild 
degrees of infantile hypertrophic stenosis. 

1 Scudder: Surgery, Gynecology and Obstetrics, 1910, xi, 275; Talbot: 
Boston Medical and Surgical Journal, 1910, clxi, 782, and 1910, clxii, 490. 

2 Scudder: Surgery, Gynecology and Obstetrics, 1910, xi, 275; Morse: 
Murphy and Wohlbach: Boston Medical and Surgical Journal,, 1908, clviii, 
480; Koplik: American Journal Medical Sciences, 1908, cxxxvi, 1. 



AND INFANT FEEDING 255 



CHAPTER XXII 
NERVOUS DISTURBANCES OF THE DIGESTIVE TRACT 

Symptoms pointing to disturbance in the digestive tract develop 
not very infrequently as the result of causes or conditions acting 
directly on the nervous system. The symptoms referable to the 
digestive tract are due to disturbance of the functions of this tract 
as the result of abnormal influences transmitted to it from the 
unduly irritable or exhausted nervous centres. The most char- 
acteristic symptoms are those due to the disturbance of the 
mechanical functions of the stomach and intestines. When the 
symptoms are due to disturbance of the secretory functions of the 
digestive tract, they are indistinguishable from those due to dis- 
turbance of these functions from other causes. In fact, the condi- 
tion is then an indigestion. Only those symptoms due to dis- 
turbance of the mechanical functions will, therefore, be described. 

The most common of the causes acting through the nervous 
system are extremes of temperature, whether of heat or cold, more 
commonly of heat. Diarrhea is a more common result than 
vomiting. The vomitus consists simply of the contents of the 
stomach and shows no evidences of indigestion. The diarrhea is 
due to increased intestinal peristalsis. The intestinal contents are, 
in consequence, hurried through the bowels. The stools are, 
therefore, normal in every way, except that they are increased in 
number and diminished in consistency. Excitement and fear may 
have the same effect as extremes of temperature. The body 
temperature is not altered in these cases. There may, however, be 
a certain amount of abdominal discomfort and general constitu- 
tional depression. 

It is conceivable that improper and indigestible food, acting 
simply as a foreign body may, through irritation of the stomach and 
intestines, reflexly cause vomiting and diarrhea without producing 
any disturbance of the digestive functions. If this occurs, it is, 
however, very uncommon. In such instances the vomitus and 
stools will contain the food which is the cause of the symptoms. 

The primary cause of many of the more chronic disturbances of 
digestion is some error in the infant's care and routine, which 
results in over-excitement and exhaustion of the nervous system, 



256 DISEASES OF NUTRITION 

rather than improper food. Constant attention, noisy surround- 
ings, lack of rest and sleep will often be found to be at the bottom 
of intractable cases of indigestion in infancy. No change in the 
diet will benefit them in any way, but they will begin to improve 
at once when the undue strain on the nervous system is removed. 

TREATMENT 

The first element in the treatment of these disturbances of the 
digestive tract due to causes acting through the nervous system is 
the removal of the cause. Recovery is usually prompt, when this 
is removed. It is also wise to omit one or two feedings and then to 
give the usual food weakened for one or two days. If the baby is 
on the breast, the duration of the nursings should be shortened and 
boiled water given before or during the nursing in order to dilute 
the milk. If the baby is taking an artificial food, it should be 
diluted with water. If the baby is on a mixed diet, the less easily 
digestible articles should be omitted. 

If the cause of the trouble is indigestible food, it is best to give a 
laxative, such as milk of magnesia or phosphate of soda, to hurry it 
out of the bowels before it can set up a disturbance of the digestion. 
A laxative is not necessary, except when improper food is the cause. 

If improper food is not the cause of the trouble and the baby is 
having a large number of loose stools, normal in other ways, it is 
allowable to diminish the excessive peristalsis by giving paregoric in 
doses of from five to twenty drops every two or four hours, accord- 
ing to the age of the child and the severity of the symptoms. 



AND INFANT FEEDING 257 



CHAPTER XXIII 
DISTURBANCES OF DIGESTION 

Disturbance of the digestion may be caused by an excess of an 
otherwise suitable food, by a too rich but otherwise well-balanced 
food and by foods containing an excessive amount of one or of 
several of the food elements. It may also be caused indirectly 
by other diseases or by any extraneous causes which weaken the 
general resistance or diminish the digestive powers. The disturb- 
ance may be either acute or chronic. The pathological changes in 
the gastroenteric tract are insignificant. In many instances there 
are no macroscopic changes beyond thinning of the intestinal wall. 
In others there is reddening of the surface and an excessive secre- 
tion of mucus, while in a few there is a desquamation of the super- 
ficial epithelium. The microscopic changes are slight and unim- 
portant. In the more chronic cases there is a general wasting of all 
the tissues of the body and in both the acute and chronic cases 
there may be degenerative changes, frequently fatty, in the paren- 
chymatous organs. The important changes are in the metabolic 
processes of the body. These are not recognizable pathologically. 
They are at present imperfectly understood. They vary according 
to which of the food elements is the cause of the indigestion. 

Disturbances of the digestion are much less common in the 
breast-fed than in the artificially-fed. The symptoms are also, as 
a rule, less severe. All disturbances of the digestion, whatever 
their cause, have many symptoms in common. The other symp- 
toms vary in accordance with the food element which is at the 
bottom of the disturbance. Disturbances of the digestion due to 
an excess of fat are likely to be more serious and more lasting than 
those due to the other food elements. Those due to an excess of 
sugar are more often acute and more often rapidly fatal. Those 
due to an excess of protein are apparently less frequent and less 
serious than those due to the other food elements. It must be 
remembered in this connection, however, that this apparent in- 
frequency may be due to failure to recognize the symptoms and 
that the protein may really be at fault when the blame is attached 
to one of the other elements. 

Simple disturbances of the digestion may be associated with 



258 DISEASES OF NUTRITION 

fermentation of the improperly digested intestinal contents as the 
result of bacterial activity. It is probable, in fact, that there is 
more or less fermentation in almost every case. When these 
fermentative processes are marked they often predominate the 
picture and the condition is then spoken of as indigestion with 
fermentation. The borderline between indigestion with bacterial 
fermentation and without it is, however, a very indefinite one. 
In many instances it is, therefore, impossible to determine in which 
class a given case belongs. 

The following classification will be adopted in discussing the 
disturbances of digestion: 

Indigestion. 

1. Indigestion from an excess of food. 

2. Indigestion from an excess of an individual food element. 

a. Fat 

b. Carbohydrates 

c. Protein 

d. Salts. 

3f Indigestion with fermentation. 

INDIGESTION FROM AN EXCESS OF FOOD 

Breast-Milk. — Indigestion from an excessive amount of breast- 
milk is comparatively uncommon, because of the fact that Nature 
tends to accommodate the supply of milk to the demand and 
because, if an excessive amount is taken, the baby is very likely to 
regurgitate it before it has had time to cause any disturbance of the 
digestion. Indigestion from an excessively rich breast-milk is also 
somewhat uncommon. 

The main symptoms of indigestion from an excessive amount of 
breast-milk or an excessively strong breast-milk are vomiting, an 
increased number of stools, failure to gain properly in weight, 
flatulence and colic. The babies are, as a rule, somewhat fussy and 
do not sleep well. The symptoms are seldom very marked. When 
the difficulty is in the strength of the milk, they are very likely to 
lose their appetites. There is nothing characteristic about the 
vomitus. The stools usually contain fat curds and more or less 
mucus. 

The condition is seldom a serious one. It is usually easily cor- 
rected. 

When there is too much milk, the duration of the nursing must 
be shortened. How much it should be shortened can usually be 
determined by observation of the baby's symptoms. More accu- 



AND INFANT FEEDING 259 

rate results can be obtained, however, by weighing the baby at 
intervals during the nursing and stopping the nursing when the 
desired amount has been obtained. The failure to empty the 
breasts will usually quickly bring about a diminution in the supply 
of milk. The mother should limit her ingestion of liquids until this 
happens. 

When the breast-milk is excessively rich, the intervals between 
the nursings should be lengthened, as this procedure tends to 
diminish the amount of solids in the milk. The mother should eat 
more simple food and should take more exercise. Water should be 
given at the time of the nursing, to dilute the milk, until the 
strength of the milk has become normal. The amount of water 
to be given depends on the age of the baby and the strength of the 
milk. It may be given with a spoon or in a bottle before or during 
the nursing, or through a dropper introduced into the mouth beside 
the nipple during the nursing. It is almost never necessary to 
wean a baby because of an excessively strong breast-milk. 

Artificial Food. — Indigestion from an artificial food, suitable 
in every way except that too much of it is given or that it is too 
strong in all its percentages, is more common than that from an 
excessive amount or strength of breast-milk, but infinitely less 
common than that from an artificial food containing an excessive 
amount of one or two of the food elements. 

The symptoms of indigestion from an excessive amount of a 
suitable food or of too strong a food are loss of appetite, vomiting, 
an excessive number of stools, flatulence and colic, and failure to 
gain in, or loss of, weight. The babies are, as a rule, fussy and 
irritable and sleep poorly. The vomitus is not characteristic, but 
may show the evidences of disturbance of the digestion of any or 
all of the food elements. The stools are also not characteristic, 
and may also show evidences of the disturbance of the digestion of 
any or all of the food elements. Evidences of disturbance of the 
digestion of fat are, perhaps, the most common. If there is a 
considerable amount of vomiting, the stools may be constipated, 
because of the lack of sufficient food remnants to form the normal 
amount of feces. 

The prognosis of indigestion due to too much of a good food or 
to an excessively rich, but otherwise suitable, food is usually good. 
The condition usually yields readily to proper treatment. 

The treatment consists primarily in cutting down the amount of 
food or in weakening the food. It is advisable in most instances to 
weaken the food considerably more than enough to bring it to the 
strength which would be suitable for the average normal baby of 



260 DISEASES OF NUTRITION 

the given age. This is necessary, because the digestive processes 
have usually been so weakened by the excessive demands upon 
them that they are unequal to meet even the usual demands. 
After the digestive powers have recovered themselves, the food can 
gradually be strengthened. It is usually possible to straighten out 
these cases without a wet-nurse. 

When the disturbance is an acute one from a temporary indis- 
cretion the intestines should be emptied with castor oil or milk of 
magnesia and all food stopped for from twelve to twenty-four 
hours. When the disturbance is a chronic one, it is often advisable 
to begin treatment with a cathartic. It is not advisable to stop 
food, even for a time. 

INDIGESTION FROM AN EXCESS OF FAT 

Breast-Milk. — Indigestion from an excessive amount of fat 
in breast-milk is comparatively uncommon. The percentage of fat 
is seldom very high and, even if it is, babies are usually able to 
accommodate themselves to it. 

The main symptoms of an excessive amount of fat in breast-milk 
are loss of appetite, vomiting and abnormal stools, with more or 
less flatulence and colic. Failure to gain in weight or a moderate 
loss of weight become manifest after a time. The symptoms are, 
however, seldom serious. There is usually nothing especially 
abnormal about the vomitus. It may, however, in the more 
severe cases, have the odor of butyric and other fatty acids. The 
stools contain many small, soft curds, and sometimes have an oily 
appearance. They are more acid than normal and may cause 
irritation of the buttocks. Soap stools are most unusual as the 
result of an excess of fat in breast-milk. 

The disturbance caused by an excessive amount of fat in breast- 
milk is seldom a severe one, is not usually of long duration and is 
ordinarily easily corrected. 

The amount of fat in the milk can sometimes be reduced by 
cutting down the fat in the mother's diet, provided she has been 
eating an excessive amount of it. In most instances, however, it 
will be found that she has been eating too much in general rather 
than too much fat. Cutting down her food as a whole, increasing 
the amount of the exercise which she takes and getting her out of 
doors more will usually promptly bring the amount of fat down to 
within normal limits. Shortening the duration of the nursings in 
order that the baby shall not entirely empty the breast is of some 
advantage, because the fore-milk contains less fat than the last 



AND INFANT FEEDING 261 

milk or " strappings." If the duration of the nursings is shortened, 
the intervals between the nursings must also be diminished in order 
that the baby may get enough food. Water may be given at the 
time of the nursing in order to diminish the percentage of fat by 
diluting the milk. This procedure has the disadvantage, however, 
of diminishing the percentage of the other food elements as well 
as that of the fat. 

Artificial Food. — Indigestion is more often due to an excess 
of fat in artificial food than to an excess of any other single ele- 
ment. The results of a disturbance of the digestion from an 
excess of fat are, moreover, more far-reaching, more lasting and 
more difficult to correct than those due to any other element. 

The symptoms are, in general, loss of appetite, flatulence and 
colic, vomiting, abnormal stools and failure to gain in weight or, 
more often, progressive loss of weight. The temperature is often 
elevated in acute disturbances of the digestion caused by fat, but is 
likely to be somewhat subnormal in the chronic disturbances. 

The vomitus is acid in reaction and has a strongly acid odor. 
This odor is due to the presence of butyric and other fatty acids. It 
sometimes has a creamy appearance. 

The most common abnormality in the stools is the presence of 
many small, soft curds. These are often accompanied by mucus. 
In other instances the stools have a gray, shiny appearance. When 
there is an excess of neutral fat, the stools may be of a creamy 
consistency and are often about the color of cream. In other 
instances they look like curdled milk. More often, especially in 
the chronic cases, the stools are gray, or grayish-yellow, large, hard 
and dry. They may sometimes be so dry as to be crumbly. The 
fat in these stools is in combination with calcium and magnesium 
in the form of soap, that is, these are the typical "soap stools." 
In other instances, the stools are watery, strongly acid, and cause 
marked irritation of the buttocks. When this happens, the fat is in 
combination with the alkaline salts, especially sodium. 

When there is an acute disturbance of the digestion as the result 
of an excess of fat in the food, there is not infrequently a high fever. 
When there is diarrhea, as there often is in the acute disturbances, 
there is not only an excessive loss of fat in the stools, but also a very 
considerable loss of alkaline salts, especially sodium. A relative 
acidosis results, with an excess of ammonia in the urine. The 
symptoms of acid intoxication may then develop. The most 
characteristic of these are rapid and deep respiration, stupor or 
restlessness, and cherry-red lips. 

When the disturbance of the digestion is a chronic one, there is 



262 DISEASES OF NUTRITION 

a continuous loss of magnesium and calcium in the stools and a 
consequent disturbance of the metabolism. This shows itself not 
only in a chronic disturbance of the nutrition but also by the 
development of the manifestations of rickets and of the symptoms 
of the spasmophilic diathesis. The manifestations of the dis- 
turbances of the nutrition as the result of the disturbance of the 
metabolism of the salts may become most marked, so that the 
babies come to present the characteristic picture of "marasmus" or 
" infantile atrophy." 

The prognosis in disturbances of the digestion due to an excess of 
fat in an artificial food depends on whether the condition is acute or 
chronic. If the condition is an acute one, it varies with the severity 
of the symptoms, but is, in general, good. If the condition is a 
chronic one, the prognosis depends on the severity of the symptoms, 
the duration of the trouble and the degree of the disturbance of the 
nutrition. It is very grave in the more marked cases and recovery 
is always slow, even in the mild cases. It always takes a long time 
to reestablish a normal tolerance for fat. Relapses are frequent and 
of long duration. The least excess of fat in the food is almost cer- 
tain to bring one on. 

The treatment of disturbances of the digestion caused by an 
excessive amount of fat in an artificial food consists in diminishing 
the percentage of fat in the food. How much the percentage of 
fat is to be cut down depends on the severity and duration of the 
symptoms in the individual instance. 

It is usually advisable to cut out the fat entirely in acute cases. 
In them, however, it can usually be cautiously added again in a 
few days. How rapidly it can be added can only be determined by 
observation of the symptoms and examination of the stools. 

It is also advisable to cut out all of the fat in beginning the 
treatment of the severe, chronic cases of fat indigestion. In the 
less serious cases it is always wise to at once reduce the percentage 
of fat materially. Time is saved, recovery is hastened and tolerance 
established much more quickly, when the percentage of fat is 
immediately cut down below the limit of tolerance than when this 
point is reached by several insufficient reductions. It is never a 
mistake to reduce the percentage of fat more than is necessary. 
Time is always lost, if the reduction is insufficient. It is usually 
advisable to reduce the fat to at least 2% in the mild cases, to 1% 
in the more severe ones, and to cut it out entirely in the most 
serious. If the stools still show an excessive amount of fat after 
the initial reduction has been made, the percentage of fat must be 
reduced still farther. If they do not show any evidences of fat 



AND INFANT FEEDING 263 

indigestion, the percentage of fat should be cautiously increased. 
Not more than 0.25% should be added at a time. Several days 
should intervene between the changes. The stools should be 
examined after each change is made to determine if this amount of 
fat is well borne before the next change is made. It must never be 
forgotten that when the tolerance for fat has once been weakened, 
it is very difficult to reestablish it and very easy to break it down 
again. 

It must be remembered, on the other hand, that the continuous 
use of a food low in fat tends to weaken the power of digesting fat 
and, therefore, to lower the tolerance for fat. It must also be 
remembered that the caloric value of fat is very high and that, if 
the percentage of fat is very low, the caloric value of the food may 
be insufficient to meet the infant's caloric requirements. When 
the percentage of fat is much diminished, the percentages of the 
carbohydrates and protein must be increased in order to cover the 
caloric needs. This is sometimes very difficult to do without setting 
up a disturbance of the digestion through an excess of one of the 
other food elements, since the caloric value of fat is more than 
twice that of sugar, starch and protein. 

Babies with an almost complete intolerance for the fat of cow's 
milk can often take the fat of human milk without difficulty. 
When, as is sometimes the case, it is impossible to feed babies hav- 
ing an intolerance for fat satisfactorily on artificial foods low in fat 
on account of the disturbance of the digestion caused by the other 
food elements, when the percentages of these elements are made 
high enough to cover the caloric needs, they should be given hu- 
man milk. In some cases unfortunately, they are unable to 
tolerate the fat of human milk. In such instances skimmed human 
milk is the only resource. 

INDIGESTION FROM AN EXCESS OF CARBOHYDRATES 

Breast-Milk. — Indigestion from an excess of sugar in breast- 
milk is decidedly uncommon. The percentage of sugar is very 
seldom over seven and, if it is 1 or 2% higher, it almost never causes 
any disturbance. 

The main symptoms of an excessive amount of sugar in breast- 
milk are flatulence and colic, vomiting and abnormal stools. The 
disturbance is seldom sufficient to cause any loss of weight. There 
is nothing especially characteristic about the vomitus. It may, 
however, sometimes have the odor of lactic or acetic acid. The 
stools are usually not especially characteristic. They are, however. 



264 DISEASES OF NUTRITION 

sometimes loose, light green in color, acid in reaction and irritating 
to the buttocks. They almost never, however, show the marked 
evidences of carbohydrate fermentation so common in the dis- 
turbances of digestion due to an excess of milk sugar in artificial 
foods. 

The disturbance caused by an excessive amount of sugar in 
breast-milk is never a severe one and is not usually of long dura- 
tion. 

It is possible that, if the mother has been taking an excessively 
large amount of sugar, a reduction in the amount of sugar which 
she takes may result in a diminution in the percentage of sugar in 
the milk. If the amount of sugar ingested has been, however, 
within reasonable limits, cutting it down cannot be expected to 
have any effect on the percentage of sugar in the milk. In most 
instances it will be found that she has been eating too much in 
general rather than too much sugar. Cutting down the food as a 
whole, increasing the amount of exercise which she takes, and 
getting her out of doors more will ordinarily quickly bring down 
the percentage of sugar to within normal limits. 

Artificial Food. — Indigestion from an excess of carbohydrates 
in an artificial food may be due to the excessive amount of either 
starch or sugar. The sugar at fault may be any one of the sugars 
commonly used in infant feeding, milk sugar, cane sugar or one of 
the dextrin-maltose combinations. The disturbances of the 
digestion caused by the various forms of carbohydrates have 
many symptoms in common. Each of them, however, also pro- 
duces certain special symptoms or combinations of symptoms 
which are more or less characteristic. 

Milk Sugar. — Milk sugar in an artificial food seldom causes 
any disturbance of the digestion, unless there is more than 7% of it 
in the mixture. Six per cent, or even 5% will, however, sometimes 
cause trouble in susceptible infants. It is never safe to give more 
than 7%. The disturbances caused by milk sugar may be either 
acute or chronic, but are more often acute. In a considerable 
proportion of the cases of indigestion resulting from an excess of 
milk sugar, a part of the symptoms are caused by the products of 
the fermentation of the sugar as the result of bacterial action. It is 
very difficult, and in many instances impossible, to determine 
how much of the symptoms are due to the disturbance of the diges- 
tion of the sugar and how much to the products of abnormal bac- 
terial activity in the sugar. 

The most prominent and characteristic symptom of a disturb- 
ance of the digestion from an excess of milk sugar is the passage of 



AND INFANT FEEDING 265 

loose, or watery, green, acid and irritating stools. They often 
contain more or less mucus. The odor is distinctly acid. In some 
instances the characteristic odors of lactic, acetic and succinic 
acids may be distinguished. The buttocks and genitals are often 
much excoriated. Vomiting is a less frequent, but is not an uncom- 
mon symptom. The vomitus is acid in reaction, and may also 
have the odor of lactic, acetic or succinic acid. It is usually 
watery. Flatulence and colic are common symptoms. Loss of 
weight is a constant and often a marked symptom in the acute 
cases; it is usually not very marked in the chronic disturbances. 
The temperature often rises rapidly and is not infrequently very 
high in the more severe acute disturbances of digestion resulting 
from an excess of milk sugar. It is seldom of long duration. It is 
doubtful, however, if the rise in temperature is directly due to the 
absorption of the sugar. It is probable that the explanation is not 
so simple. The temperature is but little, or not at all, elevated in 
the more chronic cases. The symptoms of intoxication may be 
very marked in the more severe acute cases. Among them may be 
mentioned restlessness and other manifestations of disturbance of 
the nervous system, marked prostration and disturbance of the 
respiratory rhythm. 

The prognosis in the severe acute cases is grave. If the patients 
survive for forty-eight hours after the onset of the severe symptoms, 
they usually recover. Improvement is generally rapid after it 
once begins. The prognosis in the chronic cases is good as to life. 
It is usually some weeks or months, however, before the tolerance 
for milk sugar is thoroughly reestablished. It is usually much 
easier, nevertheless, to overcome an intolerance for milk sugar than 
one for fat. 

In the acute disturbances of the digestion from an excess of milk 
sugar, milk sugar must be eliminated as far as possible from the 
food. < It must be remembered in this connection that whey con- 
tains between 4.5% and 5% of milk sugar. Whey and whey mix- 
tures are, therefore, contraindicated in this condition. Fat is also 
usually not well tolerated. Small percentages of starch are ordi- 
narily well borne. This is because the starch is broken down slowly 
and because its end-product, dextrose, is quickly absorbed. There 
is, therefore, never much sugar in the intestine at one time. The 
indications are, therefore, for mixtures containing but little fat and 
milk sugar and a considerable amount of protein, with or without 
the addition of starch. Mixtures containing from 0.50% to 1% of 
fat, 1% to 1.50% of milk sugar and 1% to 2% or even 2.50% of 
protein, with from 0.50% to 0.75% of starch are suitable ones. 



266 DISEASES OF NUTRITION 

Mixtures of skimmed milk with a cereal diluent, in various propor- 
tions, also meet these indications. It is usually somewhat difficult 
to cover the caloric needs of the infants with mixtures of this 
general character. It is therefore advisable, after a few days, to 
add one of the dextrin-maltose combinations to the mixture, in 
order to bring up its caloric value. It is usually possible to return 
after a short time to milk sugar. Eiweissmilch sometimes works 
very well in these cases. So also do mixtures prepared with pre- 
cipitated casein, because in this way high percentages of protein can 
be given in combination with very low percentages of milk sugar. 

Human milk is contraindicated in these cases, because of the 
high percentage of milk sugar which it contains. It is usually well 
borne, however, after the acute symptoms have subsided and in 
convalescence is, as always, the best food. 

In the more chronic disturbances of digestion due to an excess of 
milk sugar, it is advisable to at once cut out all the milk sugar which 
is being added to the food, thus reducing the percentage of milk 
sugar to that which is necessarily put into the food in the cream and 
milk. If the mixture is in other respects a suitable one, the per- 
centages of the fat and protein may be left unchanged. It is often 
advisable, however, to increase the percentage of protein a little, 
in order to bring up the caloric value of the food. The percentage 
of fat may also be increased for the same reason, but this must be 
done cautiously, because there is very likely to be a diminution in 
the tolerance for fat when there is a disturbance in the digestion of 
milk sugar. If the caloric value of the food is still too low, it may 
be increased after a few days by the addition of one of the dextrin- 
maltose combinations. Starch may also be added to the amount of 
0.50% or 0.75%. 

In mild cases it is often possible to gradually put back enough of 
the milk sugar, increasing it 0.50%, or even 1.00%, at a time, to 
cover the caloric needs without causing a recurrence of the symp- 
toms. In such instances it is not necessary to fall back on the 
dextrin-maltose preparations or starch. It is advisable to replace 
the dextrin-maltose preparations by milk sugar as soon as this is 
possible. 

Whey and whey mixtures are contraindicated in these cases, 
because of the high percentage of milk sugar in whey. Eiweiss- 
milch or mixtures prepared with precipitated casein are often 
useful in these cases, because a high percentage of protein may be 
given in this way in combination with a very low percentage of 
milk sugar. One of the dextrin-maltose preparations of starch may 
be added to these mixtures, if desired. 



AND INFANT FEEDING 267 

Cane Sugar. — The symptoms of disturbance of the digestion, 
whether acute or chronic, from an excess of cane sugar in the food 
are essentially the same as those from an excess of milk sugar. 
Extreme elevations of the temperature in acute disturbances are, 
however, somewhat less common. Babies that get a large amount 
of cane sugar in their food not infrequently show evidences of dis- 
turbance of the nutrition for some time before the appearance of 
the symptoms of disturbance of the digestion. They become fat, 
flabby and pale and their resistance to infection and disease is 
materially diminished. 

The prognosis in disturbances of the digestion due to an excessive 
amount of cane sugar is essentially the same as that in the dis- 
turbances due to milk sugar. It is not quite as good in the chronic 
cases, however, because of the greater disturbance of the nutrition 
produced by the long-continued use of large amounts of cane 
sugar. 

The treatment of disturbances of the digestion due to an exces- 
sive amount of cane sugar is along the same lines as when the 
disturbance is caused by milk sugar. The cane sugar should be at 
once cut out entirely, the percentage of sugar in the food thus being 
reduced to that of the milk sugar which is contained in the cream 
and milk in the mixture. After the symptoms of disturbance have 
ceased the percentage of sugar can then be gradually increased by 
the addition of milk sugar. If the symptoms recur when milk 
sugar is added to the mixture, one of the dextrin-maltose prepara- 
tions can be substituted for it. Starch may also be added in order 
to increase the caloric value of the food. 

Dextrin-Maltose Preparations. — The symptoms of disturb- 
ance of the digestion from an excess of one of the dextrin-maltose 
preparations are similar to those caused by the other sugars. The 
odor of the vomitus is acid, as in the case of the other sugars, but 
this odor is somewhat different, probably because of the presence 
in many instances of butyric acid. Flatulence and colic are usually 
more marked than when the disturbance is caused by the other 
sugars. The stools are usually loose or watery, and dark-brown in 
color, but are sometimes green. The odor is usually a peculiarly 
acrid one. Sometimes, however, it is that of butyric acid. The 
stools are strongly acid in reaction and cause very marked irritation 
of the buttocks, thighs and genitals. The elevation of the tempera- 
ture in acute cases due to an excess of the dextrin-maltose prepara- 
tions is usually less than when they are due to the other sugars. 

The prognosis in the disturbances of the digestion caused by the 
dextrin-maltose preparations is somewhat better than in those 



268 DISEASES OF NUTRITION 

brought on by the other sugars. The acute disturbances are 
usually rather less severe and both the acute and chronic disturb- 
ances are somewhat more amenable to treatment. 

The treatment of the disturbances of the digestion caused by an 
excess of the dextrin-maltose preparations is along the same lines as 
when the trouble is due to the other sugars. It consists primarily 
in the immediate withdrawal of the preparation. After one or 
two days the preparation may be cautiously added again or, as is 
usually better, milk sugar substituted for it. When an intolerance 
for sugar in general has been established, the caloric value of the 
food may be raised by increasing the percentage of protein in the 
food and adding starch. It must be remembered in this connection 
that the larger the proportion of maltose in these dextrin-maltose 
preparations, the greater, in general, is their laxative action. 
Sometimes, therefore, in the mild chronic disturbances of digestion, 
the substitution of another preparation containing a larger propor- 
tion of the dextrins will relieve the symptoms. 

Starch. — The disturbances of digestion caused by foods com- 
posed entirely of starch are more often chronic than acute. Vomit- 
ing is a relatively uncommon symptom. Flatulence and colic are 
more common. The bowels are sometimes constipated ; sometimes 
there is diarrhea. When the bowels are constipated the stools are 
small and brown. In some instances they are dry and crumbly. 
Constipation in these instances is the result of the insufficient 
amount of food, so much of the food being absorbed that there is 
but little left over to form feces. These stools have but little odor. 
Their reaction varies from acid to alkaline, according to whether 
the bulk of the stool is formed from starch remains or from the 
intestinal secretions. 

When the stools are loose the color is brown and they have the 
appearance of mucus. In fact, they are often thought to contain 
mucus or to be composed entirely of mucus. The addition of some 
preparation of iodine to them will, however, turn them dark blue, 
showing that they are composed of unchanged starch and not of 
mucus. If the condition is not severe enough to give the starch 
test macroscopically, it will be plainly visible microscopically. 
These stools are acid in reaction. Their odor is acid, but only 
slightly so. 

The disturbance of the nutrition caused by foods composed 
entirely of starch is far more serious than the disturbances of the 
digestion. This disturbance of the nutrition is due in part to the 
insufficient caloric value of these foods, but far more to their 
deficiency in protein and salts. Babies fed exclusively on starchy 



AND INFANT FEEDING 269 

foods may seem to thrive for a time in that they gain in weight, are 
of a fair color, and seem lively and well. Careful examination, 
even at this time, will show, however, that there is an exaggerated 
muscular tonicity. This is an early manifestation of the disturb- 
ance of nutrition. In a few weeks, however, they begin to lose in 
weight and color and their muscles become flabby. If the exclu- 
sively starchy diet is continued, they gradually take on all the 
characteristics of the starved, atrophic infant. Many of them die 
of intercurrent infections, however, before reaching this stage, the 
resistance to infection being especially lowered in the disturbances 
of nutrition caused by a diet consisting entirely of starch. 

The prognosis in these cases of chronic disturbance of the diges- 
tion due to an exclusively starchy diet is always a grave one, partly 
because of the marked disturbance of the nutrition and partly 
because of the marked lowering of the resistance to infection in- 
duced by it. It is always many weeks, and often months, before 
the disturbance of the nutrition is entirely overcome. The progno- 
sis in the acute cases is very good. They are usually very amenable 
to proper treatment. 

The treatment in the acute cases is the immediate and complete 
withdrawal of the starchy food. A modified milk, in which the 
percentages are all low and in which the relation of the fat, milk 
sugar and protein to each other are similar to those in human milk, 
can usually be given at once. Examples of such mixtures are: 

Fat 1.00% 

Milk Sugar 4.00% 

Protein 0.75% and 

Fat 2.00% 

Milk Sugar 5.00% 

Protein 1.25% 

Whey and whey mixtures are often useful under these conditions. 

The treatment in the chronic cases is along the same lines. It is 
more difficult to fit the food to the digestive capacity in these cases, 
however, because the functions of the digestion and metabolism of 
fat and protein have usually been materially weakened by disuse 
and by the impairment of the nutrition. It is always advisable in 
these cases, therefore, to give human milk, if it can possibly be 
obtained. 

The disturbance of the nutrition when the purely starchy foods 
are partially dextrinized is as great as when they are not. The 



270 DISEASES OF NUTRITION 

symptoms of disturbance of the digestion from starch are, however, 
diminished, although those from an excess of malt sugar may take 
their place. When the dextrin-maltose preparations or other 
sugars are added to the starchy foods their caloric value is in- 
creased and to this extent the disturbance of the nutrition is 
diminished. That due to the deficiency of protein and salts is, 
however, unaffected. The symptoms of disturbance of the diges- 
tion caused by these sugary and starchy foods are a combination of 
those" due to an excess of starch and of those due to an excess of 
sugar. The symptoms caused by the excess of sugar usually 
predominate. 

When starch is added in excess to a food of which milk forms the 
basis it causes but little disturbance of the nutrition and relatively 
little disturbance of the digestion. It seldom causes vomiting, but 
not infrequently causes flatulence and colic. It sometimes makes 
the stools harder and drier. It more often causes a looseness of the 
bowels. The stools are more acid than normal, have an acid odor 
and irritate the buttocks. The undigested starch may be visible 
in the movements and may be mistaken for mucus. If it is visible, 
it will turn dark blue when a preparation of iodine is added to the 
stool. If it is not visible macroscopically, it can be found in all 
cases microscopically. It is almost invariably associated with the 
presence of numerous iodophilic bacteria. These organisms are 
often found, moreover, before starch itself can be detected and, 
when found, they always suggest that a disturbance of the diges- 
tion from starch is imminent. 

Disturbance of the digestion from starch is much less likely to 
occur, if the starch is thoroughly cooked. It almost never develops 
unless there is 1% or more of starch in the mixture. 

The prognosis of the disturbances of digestion caused by an 
excess of starch in mixtures the basis of which is milk is good. 
Recovery is ordinarily prompt when the cause is removed. 

The treatment consists in cutting the starch entirely out of the 
food for a time. It can ordinarily be put back in reasonable 
amounts after a short time. The trouble will seldom recur, if the 
percentage of starch is not over 0.75%. 

INDIGESTION FROM AN EXCESS OF PROTEIN 

Breast-milk. — Indigestion from an excess of protein in human 
milk is much more common than from an excess of either fat or 
milk sugar. The protein is more likely to be excessive during the 
early part of lactation, before the equilibrium of the milk has been 



AND INFANT FEEDING 271 

established and the mother has resumed her normal life, than 
later. The excess of protein may be due to anxiety or nervousness 
on the part of the mother, or to either fatigue or lack of exercise, 
all of which increase the protein content of the milk. It is impossi- 
ble to know in advance what percentage of protein will be an excess 
for the individual infant. Some babies are disturbed if the protein 
is more than 1.50%, while others can take 2.50% or even 3.00% 
without being disturbed in any way. 

Vomiting, while it does occur, is a comparatively uncommon 
symptom of indigestion from an excess of protein in breast-milk. 
Flatulence and colic, on the other hand, are very common symp- 
toms and are often very marked and very troublesome. There is 
almost invariably an increase in the number of the stools, which are 
either loose or watery. They are usually brownish-yellow instead 
of golden in color, but may be green. They not infrequently con- 
tain mucus and often fine, soft, fat curds. These may be due to a 
coincident fat indigestion, but are more often due to the increased 
peristalsis and consequent interference with absorption. The 
reaction is alkaline or feebly acid. The odor is not characteristic. 
It may be acid or a little foul. The stools do not ordinarily irritate 
the buttocks. The temperature may be slightly elevated, but 
ordinarily is not. In some instances, however, when the disturb- 
ance is an acute one from a sudden and marked increase in the 
percentage of protein, the temperature may be considerably 
elevated. The nutrition is not as much affected as would be 
expected from the amount of digestive disturbance. There is 
ordinarily not much loss of weight. Many babies continue to gain, 
although slowly, while occasionally a baby will gain rapidly in spite 
of much colic and many loose stools. 

Disturbance of the digestion from an excess of protein in breast- 
milk is usually rapidly recovered from, if the cause of the excess can 
be removed. The results are seldom lasting. In rare instances, 
however, when there is a sudden and very marked increase in the 
percentage of protein, the babies may die within a few days. It is 
possible, however, that the cause of death in such cases may not 
be the excessive amount of protein but some unrecognizable 
chemical change in the milk. 

The treatment of indigestion from an excess of protein in breast- 
milk consists primarily in regulation of the mother's diet and life in 
order to reduce the percentage of protein in the milk. When the 
/percentage of protein is excessive, while the percentages of fat and 
-sugar are within normal limits, it is probably impossible to dimin- 
ish the percentage of protein alone by any change either in the 



272 DISEASES OF NUTRITION 

quantity or quality of the food. When the percentages of fat and 
sugar, as well as that of the protein, are high, it is possible to reduce 
them all simultaneously to a certain extent by cutting down the 
amount of food and increasing the amount of exercise which the 
mother takes. Increasing the length of the intervals between the 
nursings will also diminish the percentage of protein together with 
those of the other elements. The percentage of protein may also be 
diminished by giving the baby water at the time of the nursing. 
The percentages of fat and sugar are, however, also diminished to 
the same extent. 

When the high percentage of protein is the result of inactivity on 
the part of the mother, it can be diminished by making her take 
more exercise. Exercise in the open air is preferable to that in- 
doors. Care must be taken, however, that she does not take too 
much exercise and become fatigued, because fatigue increases the 
protein. If the excess of protein in the milk is due to fatigue or 
overwork, it can be diminished by resting the mother and keeping 
her more quiet. 

When the high percentage of protein is due to nervousness, 
worry or anxiety, the remedy is obvious. The removal of the 
cause will at once result in a diminution in the percentage of 
protein. It is, however, unfortunately, seldom possible to modify a 
woman's natural temperament and frequently very difficult to 
remove causes of anxiety and worry. 

Artificial Food. — A disturbance of the digestion is almost never 
due to an excess of protein in an artificial food, unless that food is 
cow's milk or some modification of cow's milk. When there is a 
disturbance of the digestion as the result of an excess of the protein 
in cow's milk, the excess is almost invariably of casein, not of whey 
protein. 

Whey Protein. — When babies that are being fed on whey or 
on mixtures containing a high percentage of whey protein have a 
disturbance of the digestion, this disturbance is in the vast ma- 
jority of instances due to the milk sugar and salts in the whey 
rather than to the whey protein itself. The symptoms are, there- 
fore, those of an excess of milk sugar and of salts. It is probable, 
however, that in rare instances the whey proteins may cause a 
disturbance of the digestion. The chief symptom of such a dis- 
turbance of the digestion is the presence of an increased number of 
loose, watery stools. There may also be flatulence and colic. The 
stools may be normal in character, except for their diminished 
consistency, but are sometimes brownish and alkaline, with a 
musty odor. 



AND INFANT FEEDING 273 

The disturbance of the digestion from an excess of whey protein 
is usually not a severe one and ordinarily yields promptly to proper 
treatment. 

The treatment of a disturbance of the digestion from an excess of 
whey protein consists in stopping the whey or diminishing the 
percentage of whey protein, and giving the necessary percentage of 
protein in the form of casein. 

Casein. — The symptoms of disturbance of the digestion from an 
excess of casein are vomiting, flatulence and colic, abnormal stools 
and disturbance of the nutrition. The vomitus often contains very 
large curds. These curds may be fairly soft or tough and leathery. 
The vomitus ordinarily has but little odor. It may smell slightly 
acid, but is never strongly acid. Flatulence and colic are often 
quite severe. The chief abnormality in the stools is the presence of 
large, hard curds. The number of stools may or may not be in- 
creased. In many instances the stools are normal in character, 
except for the presence of the curds. In other instances, however, 
there may be an increased number of loose or watery stools, brown- 
ish in color and alkaline in reaction. The odor is musty. These 
stools at times contain an excess of mucus, but almost never curds. 
The disturbance of the nutrition from an excess of casein in the 
food is usually not very marked. There is ordinarily no fever, but 
in some instances it is moderately elevated. If the temperature is 
high, it is probably due to some other cause, such as an excess of 
salts. 

The prognosis of disturbances of the digestion caused by an 
excess of casein is usually good. It is not a difficult matter, in most 
instances, to correct the disturbance by diminishing the percentage 
of casein or by the use of one of the numerous methods for prevent- 
ing the formation of large casein curds. 

When the disturbance of the digestion of protein results in the 
passage of watery, brown, musty stools, the protein must be cut 
entirely out of the diet for a time and some form of carbohydrate 
be given in its place. Any of the cereal waters, to which milk 
sugar or one of the dextrin-maltose preparations may be added, is 
suitable. Protein, best in the form of casein, must be added again 
as soon as possible, however, in order to prevent serious disturbance 
of the nutrition from the loss of body protein as the result of the 
lack of protein in the food. 

When the disturbance of digestion shows itself by the vomiting 
of large curds, flatulence and colic, and the passage of large, hard 
curds in the stools, the object of the treatment is to prevent the 
formation of large curds in the stomach. If they are not formed 



274 DISEASES OF NUTRITION 

there, they will not be formed lower down. If the formation of 
large curds can be prevented, the casein will, in most instances 
cause no disturbance. The simplest way to prevent the formation 
of large casein curds is to diminish the percentage of casein in the 
milk mixture. When this plan is adopted, great care must be taken 
not to diminish the percentage of protein so much that the protein 
need of the baby is not covered. 

A portion of the protein may be given in the form of whey 
protein. In this way the formation of large curds is prevented and 
yet the protein need of the baby can be covered. There are many 
methods for preventing the formation of large casein curds. These 
methods are very different, but the result obtained with all of them 
is the same. In some way or other the production of large casein 
curds is prevented or at least hindered. Some of these methods are 
boiling the milk, the addition of cereal diluents, the addition of 
lime water or other alkalis to the mixture, the addition of citrate of 
soda, and " peptonization" of the milk. Another way of prevent- 
ing the formation of large casein curds is by using buttermilk. Still 
another way is by the use of precipitated casein in the milk mix- 
tures, or in the form of Eiweissmilch. It is often very hard to 
decide which method to use in a given case. A careful study of the 
conditions in the case and a thorough comprehension of the way in 
which the formation of casein curds is prevented in each method 
will usually show, however, which one is the most suitable one 
under the circumstances. These methods are fully described on 
pages 202 to 205. 

INDIGESTION FROM AN EXCESS OF SALTS 

There is no doubt that the salts play a most important part in 
the metabolism of the other food elements and that the metabolic 
processes cannot progress normally unless the proper salts are 
present in the proper proportions. There is unquestionably a 
disturbance of the metabolism of the salts in all disturbances of 
nutrition in infancy. It is very difficult to determine, however, 
whether the disturbance of the nutrition in any given case is due 
primarily to a disturbance of the salt metabolism from an insuffi- 
ciency or improper combination of the salts in the food or whether 
the disturbance of the salt metabolism is secondary to an in- 
sufficiency, excess, or improper combination of one or more of the 
other food elements and to the disturbance of the digestion caused 
by them. 

There is no doubt, moreover, that the salts play an important 



AND INFANT FEEDING 275 

part in every digestive disturbance in infancy. It is probable, but 
not certain, that the salts may of themselves cause disturbance of 
the digestion independently of the other food elements. Very 
little is known as to the symptoms which an insufficiency or an 
excess of the salts as a whole in the food may cause. If the salts are 
cut out of a food, which is otherwise unchanged, the weight falls. 
When they are put back again, the weight rises. This variation in 
the weight is probably largely, but not entirely, due to variations 
in the retention of water. The sodium salts favor the retention of 
water. The salts of calcium diminish its retention to a moderate 
extent. It is also known that the withdrawal of salts from the 
food results in a lowering of the body temperature. An excess of 
calcium in the food also lowers the temperature. If a large amount 
of sodium chloride is given to a baby suffering from a disturbance of 
the digestion, there is usually a rise in the temperature. If there is 
no disturbance of the digestion, there is ordinarily no elevation of 
the temperature. Variations in the weight and temperature are, 
however, common to all disturbances of the digestion and do not, 
therefore, justify the diagnosis of indigestion as the result of some 
abnormality in the salts of the food. There being no symptoms 
peculiar to abnormalities in the salts of the foods, it is, therefore, 
impossible at present to make a diagnosis of indigestion from an 
excess or from an improper combination of the salts in the food. 
The condition may be suspected, but that is all. 

It being impossible to make a positive diagnosis of indigestion 
from an excess or an improper combination of the salts in the food, 
it is evidently impossible to make a definite prognosis or to lay 
down any rules for treatment. 

The Medicinal Treatment of Disturbances of the Digestion 
in Infancy. — The treatment of the disturbances of digestion in 
infancy consists primarily in regulation of the diet. All other 
methods of treatment are relatively unimportant. They have 
their place, however, and cannot be dispensed with. They are 
especially useful for the relief of symptoms. 

In the first place, the bowels should be thoroughly cleaned out 
in every acute disturbance of the digestion, whatever its cause, 
unless this disturbance is very slight. The most useful drug for 
this purpose is castor oil, because it is effective, acts quickly and 
causes less irritation of the bowels than calomel* and strong salines. 1 
The dose should be from one to three teaspoonfuls, according to 
the age of the baby and the effect desired. Babies do not, as a 
rule, object to the taste of castor oil. In fact, most babies like it. 
1 Abt. Archives of Pediatrics, 1909, xxvi, 836. 



276 DISEASES OF NUTRITION 

No attempt should be made, therefore, to disguise its taste. The 
stools produced by castor oil always contain mucus. Too much 
importance must not be attached, therefore, to the presence of 
mucus in the stools after a dose of castor oil. 

If less vigorous catharsis is desired than that usually produced by 
castor oil, milk of magnesia may be used in its place. The dose is 
from one to three teaspoonf uls, according to the age of the baby and 
the effect desired. It may be given in the food, plain, or diluted 
with water. 

Castor oil should be tried first, even if the baby is vomiting. It 
will often be retained when food is vomited. If it is vomited, 
calomel may then be tried. It is best given in doses of one-tenth 
of a grain combined with one grain of bicarbonate of soda, every 
half-hour, until one grain has been taken. It is advisable, but not 
necessary, to give one or two teaspoonf uls of the milk of magnesia 
three or four hours after the last dose of calomel. It should not be 
forgotten that calomel often gives the stools a peculiar green color 
that may be mistaken for that resulting from disturbances of the 
digestion in which the stools are excessively acid. 

If the disturbance of the digestion is acute, severe and associated 
with considerable elevation of the temperature, it is also advisable 
to wash out the colon with salt solution or at least to give an enema 
of suds to clean out the bowel from below. 

When the disturbance of the digestion is a chronic one, it is, as a 
rule, inadvisable to begin treatment with an initial catharsis. 
Catharsis is a weakening procedure and, when a baby is in a 
debilitated and feeble condition as the result of a long disturbance 
of the nutrition, is liable to do serious injury. When the disturb- 
ance of nutrition is extreme it may, in fact, take away the baby's 
last chance of recovery. 

When babies with acute disturbances of digestion are vomiting, 
all food should be stopped. They may be given water to which 
bicarbonate of soda, in the proportion of one level teaspoonful to 
eight ounces of water, has been added, in teaspoonful doses, every 
ten to thirty minutes. If the vomiting is severe or persistent, the 
stomach should be washed out once or twice daily with a solution 
of bicarbonate of soda of the strength of one rounded teaspoonful 
to a pint of water. 

It is not a difficult matter to wash out the stomach of a baby. 
There is usually no difficulty in introducing the catheter, even in 
the youngest baby. A soft rubber catheter, No. 16, American 
scale, or one a little smaller is used. The catheter should be at- 
tached by a short piece of glass tubing to a rubber tube attached to 



AND INFANT FEEDING 277 

a funnel. The baby should be well wrapped up and it and the nurse 
protected by a rubber apron or sheet. The baby should be held 
upright in the nurse's lap, facing forward and bending a little 
forward. The mouth can be held open by the forefinger of the 
left hand, around which a towel may be wrapped. The catheter, 
which is held in the right hand, is then pushed to the back of the 
throat and downward. It passes most easily when the baby gags. 
The distance from the gums or incisor teeth to the cardia during 
infancy is between seven and eight inches. The catheter should, 
therefore, not be introduced farther than this. It is very difficult 
to pass the catheter anywhere except into the esophagus. It is 
possible, however, to pass it through the larynx. Water should 
never be poured in, therefore, until the baby has cried clearly or 
food has come up through the tube. It is easier to start the si- 
phonage if the tube is introduced full of water. The washing should 
be continued until the water returns clear. 

It is rarely necessary or advisable to give an emetic to infants 
suffering from disturbances of the digestion. A teaspoonful of the 
wine of ipecac is the safest and best, if an emetic is necessary. 

The best treatment for the flatulence and colic associated with 
disturbances of digestion is the removal of the cause. This is done 
by regulation of the diet. While the cause is being removed, the 
symptoms must, however, be relieved, if possible. It is advisable 
to try the simplest remedies first. These are hot applications to the 
abdomen and hot water by the mouth. If these measures are not 
effective, a quarter or a half of a soda mint tablet dissolved in an 
ounce of hot water may be tried, or from two to five drops of the 
essence of peppermint in the same amount of hot water. Five or 
ten drop doses of the elixir of catnip and fennel (Wyeth's) in one or 
two tablespoonfuls of hot water are sometimes useful. An enema 
of warm water will almost always stop the colic if other measures 
fail. It is very seldom necessary or advisable to use any form of 
alcohol or paregoric. Flatulence and colic are often due to the 
swallowing of air during the act of nursing, whether from the 
breast or bottle. The swallowed air tends to collect in the fundus. 
After the stomach is partially full the air cannot reach and be 
discharged through the cardiac orifice. If the baby is picked up 
from time to time during the nursing, held upright and its back 
patted, the air can escape and the flatulence and colic will be pre- 
vented. 

There is little or no place for the so-called "digestants" in the 
treatment of disturbances of digestion in infancy. There is almost 
never a deficiency of either pepsin or hydrochloric acid in the gas- 



278 DISEASES OF NUTRITION 

trie secretion and rennin is always present. The pancreatic fer- 
ments cannot pass through the stomach without being destroyed. 
The only place for the digestive ferments in the treatment of these 
conditions is, therefore, in predigesting the foods before they are 
taken by the infant. 

There is little or no absorption of fat through the skin, certainly 
not enough to have any appreciable effect on the nutrition. The 
only way in which inunctions of cod liver or other oils in chronic 
disturbances of nutrition can be of use, therefore, is through the 
stimulation of the peripheral circulation and muscular tone incident 
to the rubbing. 

It is advisable to stop the food entirely for from twelve to forty- 
eight hours in all the acute disturbances of digestion from whatever 
cause. There is no danger in stopping the food, if the baby is given 
as much water as it would take of food. Babies can get along very 
well for a time without food, but they cannot get on without water. 
If they object to plain water, they will usually take it gladly if it is 
sweetened with saccharin. There is no objection to giving it in the 
form of very weak tea, sweetened with saccharin, if the babies like 
it better in this way. The length of time during which food is 
withheld depends on the severity of the symptoms in the given case. 

Great care must be exercised in stopping the food of babies 
suffering from chronic disturbances of the nutrition, even when 
there is an acute exacerbation of the symptoms. Such babies are 
in no condition to bear acute starvation on top of a chronic inani- 
tion. In fact, the complete withdrawal of food is very likely to 
kill them. It is much wiser, therefore, under these conditions, to 
weaken or change the food than to stop it entirely. 



AND INFANT FEEDING 279 



CHAPTER XXIV 
INDIGESTION WITH FERMENTATION 

The term, indigestion with fermentation, is used to distinguish a 
condition in which fermentation takes place in the intestines as the 
result of the abnormal growth and activity of microorganisms in the 
intestinal contents. The term fermentation is used here in its 
broad sense and includes all the changes which take place in the 
various food elements as the result of the action of microorganisms 
upon them. In some instances the microorganisms concerned are 
the normal inhabitants of the intestinal tract, in others they do not 
belong to the normal intestinal flora. 

It is extremely difficult to draw a distinct line between simple 
indigestion and indigestion with fermentation on the one hand and 
between indigestion with fermentation and infectious diarrhea on 
the other. It is assumed in the first instance that there is no 
fermentation in simple indigestion. This assumption is, of course, 
not strictly true, because there is unquestionably a certain amount 
of fermentation under normal conditions and more in simple in- 
digestion. In simple indigestion, however, the fermentation plays 
but a small part in either the pathology or symptomatology of the 
condition and none in the etiology. In indigestion with fermenta- 
tion, however, fermentation plays the major role. Whether the 
abnormal bacterial activity develops secondarily as the result of 
disturbances of the normal processes of digestion or appears 
primarily as the result of the introduction of an excessive number 
of bacteria, whether or not they are members of the ordinary intes- 
tinal bacterial flora, into the intestine or as the result of a change in 
the normal relations of the bacteria to each other from a badly bal- 
anced diet, the symptoms are due in the main to the presence of the 
abnormal products of bacterial activity. It is assumed in the 
second instance that in indigestion with fermentation there are no 
pathological lesions in the intestinal wall and that no micro- 
organisms pass from the intestines into the general circulation. 
These assumptions are also not strictly true, because there are, 
without doubt, some minor changes in the intestinal wall in severe 
cases of indigestion with fermentation and it is presumable that 
an occasional microorganism enters the blood stream. The 



280 DISEASES OF NUTRITION 

intestinal lesions are, however, never marked, in contradistinction 
to the severe lesions characteristic of infectious diarrhea. It is 
presumable, moreover, although not proven, that in infectious 
diarrhea microorganisms frequently pass into the circulation, 
perhaps in considerable numbers. 

Etiology. — So little is known accurately as to the normal intes- 
tinal flora and as to the normal variations in the relation of the 
individual elements of this flora to each other as the result of 
changes in the relative proportions of the various food elements, 
that it is extremely difficult to draw any positive conclusions from 
the microscopic examination of the stools, not only as to what 
organism or organisms are causing the trouble in a given case, but 
also as to what organisms may in general cause excessive fermenta- 
tive changes. Furthermore, it is by no means always safe to draw 
positive conclusions as to the intestinal bacteria from an examina- 
tion of the fecal bacteria. There is a certain amount of fairly 
satisfactory evidence to show that butyric acid bacilli, the B. 
acidophilus, and the B. putrificus may cause abnormal fermenta- 
tive changes in the intestinal contents. It is probable that under 
certain conditions the colon bacillus may also be the cause of ab- 
normal fermentative processes. The unrestrained and excessive 
activity of the normal lactic acid forming organisms of the in- 
testinal flora may also result in an excessive acid fermentation 
sufficient to cause definite and severe symptoms. The B. per- 
fringens, described by Tissier * has been proved more positively 
than any other organism to be the cause of fermentative diarrhea. 

Pathology. — The pathological changes in the intestine in indiges- 
tion with fermentation are comparatively slight. In most instances 
there is presumably nothing more than an injection of the mucous 
membrane, while in the most severe cases the process does not 
progress beyond that of a mild catarrhal inflammation. 

In the more severe cases of indigestion with fermentation there 
are more or less marked degenerative changes in the parenchy- 
matous organs, especially in the liver and kidneys. True inflam- 
mation of the kidneys is, however, uncommon. Secondary infec- 
tion of other organs, such as the middle ears and lungs, as the result 
of the general weakened resistance, are not uncommon in the se- 
rious cases. 

Symptomatology. — Indigestion with fermentation is more often 

acute than chronic. When it is acute, there is in most instances 

some elevation of the temperature. The height of the temperature 

depends presumably on the amount of toxic absorption. In the 

1 Annates de l'Institut Pasteur, 1905, xix, 273. 



AND INFANT FEEDING 281 

most severe cases it may be as high as 104° F. or 105° F., or even 
higher. Such high temperatures do not, however, usually last 
more than three or four days, although the temperature may be 
moderately elevated for some days longer. The temperature is 
ordinarily but little, if at all, elevated in the chronic cases. 

The appetite is usually impaired. Vomiting is unusual, and there 
is nothing characteristic about it, when it does occur. There is 
usually more or less abdominal discomfort, and the abdomen is not 
infrequently distended. There is, of course, always more or less 
loss of weight. 

Diarrhea is a marked symptom in almost all cases of indigestion 
with fermentation. The character of the stools depends upon 
which of the food elements is being attacked by the microorganisms 
which are the cause of the trouble in the individual case. In the 
vast majority of instances indigestion with fermentation is due to 
organisms which produce fermentative changes in carbohydrates 
and to a less extent in fats. The stools are, therefore, usually green 
in color, strongly acid in reaction and odor, and irritating to the 
skin. They often contain a considerable amount of mucus, as the 
result of the irritation of the intestinal mucosa by the highly acid 
intestinal contents. They are often frothy and not infrequently 
contain many small, soft, fat curds. When the disease is caused 
by the abnormal activity of proteolytic organisms the stools are 
more often yellow or yellowish-brown than green. They are 
ordinarily alkaline in reaction and have a foul odor. They seldom 
contain curds, and mucus is a less prominent constituent. In one 
type of this class of cases the stools are rather characteristic, being 
frequent, small, watery, dark-brown, alkaline and with a peculiar 
musty odor. 

There is almost always a moderate polynuclear leucocytosis in 
these cases, if they are at all severe. It is ordinarily not over 
20,000, but in the severest cases may be much higher. In them, 
however, the toxemia may be so great that the system is over- 
whelmed. In such instances there is no leucocytosis. 

The urine is usually diminished as the result of the loss of fluid 
through the bowels and the diminution in the intake. In the 
severe cases it not infrequently shows the evidences of acute 
degeneration of the kidneys. Acute inflammation of the kidneys 
is very unusual. The urine rarely contains sugar, unless the 
toxemia is extreme or very large amounts of sugar are being 
ingested. 

In the most severe and fatal cases certain symptoms, such as un- 
controllable vomiting, marked prostration and hyperpyrexia, are 



282 DISEASES OF NUTRITION 

likely to develop. In others there may be marked symptoms of 
irritation of the nervous system. These symptoms are in all prob- 
ability due largely to toxic absorption from the intestines. They 
are more fully described in the chapter on Infectious Diarrhea, in 
which disease they also frequently develop. 

Diagnosis. — The two conditions with which indigestion with 
fermentation may be confused are simple indigestion and infectious 
diarrhea. It is often very difficult to distinguish between simple 
indigestion and indigestion with fermentation, because of the fact 
that all but the mildest cases of simple indigestion are accompanied 
by a certain amount of fermentation in the intestinal contents as the 
result of bacterial activity in them. The border line between them 
is, therefore, a very indefinite one and must often be arbitrarily 
drawn. The manifestations of simple indigestion of the various 
food elements are, moreover, very similar to those of fermentation 
of these same elements as the result of abnormal bacterial action. 
This makes it still more difficult to draw the line. It has to be 
drawn principally on the relative severity of the symptoms in 
general and especially on the degree of the evidences of fermenta- 
tion. When these predominate the picture, the diagnosis of 
indigestion with fermentation is justified. In general, moreover, 
the constitutional symptoms are more severe, the temperature 
higher, and the manifestations of toxemia more marked in indiges- 
tion with fermentation than in simple indigestion. 

Mild or moderately severe cases of indigestion with fermentation 
are not likely to be confused with infectious diarrhea. The more 
severe cases, with high fever, marked evidences of toxic absorption 
and considerable amounts of mucus in the stools may, however, be 
mistaken for it. It is very often difficult to differentiate between 
them and it is not infrequently impossible to make a positive 
diagnosis. The most important single symptom in the diagnosis is 
probably the temperature curve, the elevation of temperature in 
severe cases of indigestion with fermentation being, as a rule, high 
and of short duration, while in infectious diarrhea, although not 
usually very high, it is constant and continuous. The stools show, 
in general, more evidences of fermentation in indigestion with 
fermentation than in infectious diarrhea, and never contain blood, 
as they do in infectious diarrhea. In a certain number of instances, 
however, a positive diagnosis can only be made by a bacteriological 
examination of the stools. 

Prognosis. — The outlook is always grave in the cases which 
show marked evidences of toxic absorption. If they survive the 
first three or four days, however, they usually recover. Those 



AND INFANT FEEDING 283 

cases in which the stools are watery and dark-brown with a musty 
odor are also always serious. The cases in which the evidences of 
carbohydrate fermentation predominate are usually milder than 
the other types and yield fairly readily to rational treatment. A 
high temperature is not, of itself, of especially bad prognostic im- 
port. Neither are the presence of considerable amounts of mucus 
in the stools or of albumin and other evidences of degeneration of 
the kidneys in the urine. The cases which have become chronic 
are likely to drag along for a long time in spite of careful treatment. 

Treatment. — It is advisable in all acute cases of indigestion with 
fermentation to at once thoroughly clean out the intestinal tract. 
The best drug for this purpose is castor oil. It works quickly, 
thoroughly and causes less irritation of the intestines than other 
cathartics. The dose should not be less than two teaspoonfuls. 
It should be given plain. If the castor oil is vomited, calomel 
should be given in its place. The usual dose is T V of a grain, com- 
bined with one grain of bicarbonate of soda, every half-hour until 
1 or lj^ grains have been given. It is wise to follow it with two or 
three teaspoonfuls of the milk of magnesia in two or three hours 
after the last dose. This treatment should be repeated, if the 
desired results are not obtained. 

All food should be stopped for from twelve to twenty-four hours. 
It is not desirable, as a rule, to withhold food longer than this. It is 
necessary, however, to give water freely during this period, because, 
although a baby can bear temporary starvation, it cannot get along 
without water. At least as much water should be given as the 
baby would ordinarily take of liquid in the form of food in the 
given time. The water may be given either warm or cool, and 
may be sweetened with saccharin, if desired. There is no objection 
to giving it in the form of weak tea, sweetened with saccharin, if it 
is taken better in this way. It should be given through a tube, if 
the baby will not take it otherwise. It is not safe to continue the 
period of starvation longer than twenty-four hours when the 
microorganisms which are causing the trouble are of the proteolytic 
type, because the intestinal secretions are protein in nature and, 
therefore, provide a suitable culture medium for proteolytic 
bacteria. There is no objection to a longer period of starvation 
when the microorganisms are of the types which thrive on fats 
and carbohydrates, if it is for any reason indicated. Preliminary 
purgation and starvation are rarely advisable in chronic cases. 

The object to be aimed at in the treatment of indigestion with 
fermentation is the destruction, or at least the inhibition of the 
activity, of the microorganisms which are the cause of the disease. 



284 DISEASES OF NUTRITION 

It is useless to attempt to do this by the administration of drugs by 
the mouth, because it is impossible to give any of the so-called 
intestinal antiseptics in large enough doses to have any effect on 
the pathogenic bacteria in the intestine without poisoning the 
baby. If they did have any action, it would be exerted, moreover, 
on the antagonistic as well as on the pathogenic bacteria. They 
would be likely, therefore, to do as much harm as good. It is 
possible that the salts of bismuth may diminish the intensity of the 
symptoms to a small extent. They do not have, however, any 
curative action. If they are used, they should be given in doses of 
from ten to twenty grains, every two hours. It is safer to use the 
subcarbonate or the milk of bismuth than the subnitrate, because 
of the danger of nitrite poisoning when the subnitrate is used. It is 
also useless to attempt to get rid of the pathogenic bacteria by 
irrigation of the bowels, because the fluid used in irrigation never 
reaches higher than the ileocecal valve, if it reaches as far as that, 
while the chief seat of the trouble is in the small intestine. 

It is possible in some instances to destroy the pathogenic micro- 
organisms, or at any rate to materially diminish their numbers and 
inhibit their activity, by the administration of antagonistic bacte- 
ria. This method has been proved to be effectual when the dis- 
turbance is due to the B. perfringens and organisms of the gas 
bacillus group. There is some evidence to show that it is of value 
when the trouble is caused by the B. acidophilus and proteolytic 
organisms. Tissier has shown that the B. bifidus has an antag- 
onistic action on the B. perfringens. It is probable that it has a 
similar action on other pathogenic organisms. It is, however, 
anaerobic and, therefore, difficult of cultivation. Its use is, on this 
account, hardly practicable clinically. Lactic acid bacilli have, 
however, an antagonistic action on all the organisms mentioned. 
It is easy to obtain them in pure cultures and in any amounts 
desired. It is probable that the Bulgarian bacillus has some 
advantages over the other varieties. The lactic acid bacilli may 
be given in the form of broth cultures, in the form of buttermilk or 
in the form of modified milk ripened by them. They are effective 
when given in any of these ways. It seems most rational, however, 
to give them in the form of ripened modified milk, because when 
given in this way the food can also be modified to suit the needs of 
the individual infant. There is a certain advantage in the use of 
buttermilk and ripened modified milk over broth cultures of the 
lactic acid bacilli, in that they contain, in addition to the or- 
ganisms, lactic acid which has been formed by them. This, in 
itself, has an antagonistic action on the growth of the pathogenic 



AND INFANT FEEDING 285 

organisms. When buttermilk and ripened modified milk are used 
in the treatment of indigestion with fermentation, they should not 
be pasteurized or boiled, because, if they are, the lactic acid or- 
ganisms are killed and can, therefore, have no effect. It is self- 
evident that, when lactic acid bacilli are the cause of the fermenta- 
tion, foods containing these organisms should not be given. 

Another way by which the number of the organisms causing 
indigestion with fermentation can be diminished and their activity 
inhibited is by a change in the character of the infant's food. A 
change in the character of the food results in a change in the 
character of the intestinal contents, that is, in the medium in which 
the pathogenic organisms are growing. If these are of the types 
which thrive on a carbohydrate medium, the percentages of the 
carbohydrates should be diminished and that of the protein in- 
creased. The percentage of fat should also be diminished, because 
when there is an abnormal fermentation of the carbohydrates there 
is very likely to be a secondary fermentation of the fat. When the 
organisms are of the butyric acid forming type the percentage of fat 
should be much diminished, that of the carbohydrates diminished 
to a moderate degree and that of the protein increased. When the 
organisms are proteolytic, the percentage of protein should be 
diminished and that of the carbohydrates increased. The general 
principles to be followed as to the choice of carbohydrates in dis- 
turbances of the digestion which have been described in the chapter 
on indigestion are equally applicable in the treatment of indiges- 
tion with fermentation. It is evident that in certain instances it is 
possible to combine both methods of treatment. 

Clinically, when the stools are loose, green, acid and irritating, 
the percentage of fat and carbohydrates in the food should be re- 
duced and that of the protein raised. It is in cases of this type that 
"albumen milk" gives such satisfactory results. Beef juice, 
broths and albumen water may also be given. When a foreign 
protein is given under these conditions, there is always a possibility 
that it may pass through the intestinal wall unchanged and sensi- 
tize the baby. This is especially liable to happen with egg albu- 
men. Albumen water should, therefore, always be used cautiously, 
if at all, in the treatment of the diarrheal diseases of infancy. Un- 
less the fermentation is due to lactic acid bacilli, buttermilk and 
ripened modified milk mixtures, containing low percentages of 
fat and carbohydrates and a high percentage of protein, give better 
results than similar modifications unripened. If the fermentation 
is due to the lactic acid bacilli, the simple modifications give, of 
course, much more satisfactory results. 



286 DISEASES OF NUTRITION 

When the stools are brownish, alkaline and foul, the percentage 
of protein should be much reduced and that of the carbohydrates 
much increased. That of the fat should be kept low. Protein 
foods, such as beef juice, broth and albumen water should not be 
given. Buttermilk and ripened modified milk mixtures containing 
a low percentage of fat and protein and high percentages of car- 
bohydrates usually give good results in these t cases. So also does 
breast-milk. 

Babies that are seriously ill with indigestion with fermentation 
are very likely to show one or more rather characteristic symptoms 
or groups of symptoms. One of these groups of symptoms almost 
invariably develops toward the end in fatal cases. These symp- 
toms are: 

(a) Excessive vomiting. 

(b) Hyperpyrexia. 

(c) Symptoms of irritation of the central nervous system. 

(d) Prostration and collapse. 

It is probable that these symptoms are chiefly manifestations of 
toxemia. It is presumable that the loss of water through the 
bowels also plays a part in their production. These symptoms also 
develop very frequently in infectious diarrhea. They and the 
treatment for them are fully described in the chapter on this 
disease. So also are the use of salt solution and stimulants in 
serious cases of diarrheal disease, 

INTESTINAL TOXEMIA OF THE NEW-BOKN 

This condition, although not a very uncommon one, is often 
overlooked or mistaken for some other disease. Being in all 
probability due to bacterial infection of the retained meconium and 
the absorption of the toxic products formed by them in the meco- 
nium, it seems more rational to consider it under the head of indi- 
gestion with fermentation than elsewhere. There are no data as to 
the nature of the causative organisms or the pathological changes. 
The clinical picture is as follows. 

Symptomatology. — A baby that was normal at birth and has 
continued to seem normal and to do well up to the second, third, 
fourth or even fifth day, becomes rather suddenly ill. He is likely 
to cry and moan considerably, although he is not infrequently 
unusually quiet. Attacks of cyanosis are a common and early 
symptom. Twitching of the extremities, slight general rigidity 
and retraction of the head come on in many instances, while 



AND INFANT FEEDING 287 

convulsions are not infrequent. The temperature is, as a rule, only 
moderately raised, but may be high. In the more severe cases the 
baby refuses to nurse. Vomiting is uncommon. In most instances 
there is no diarrhea; in fact, the tendency is to constipation. The 
symptoms develop in the majority of instances before the baby has 
ceased to pass meconium and it is- very common to find that it has 
not passed as much as the average baby. If the stools are not 
composed of meconium, they are usually small in amount, loose, 
dark-brown and contain small, soft curds and mucus. They are 
often offensive. The abdomen may be distended, but usually is 
not. Loss of weight is generally rapid, the face becomes pinched 
and in all but the mildest cases it is evident that the baby is 
seriously ill. If the bowels are thoroughly cleaned out, all food 
stopped for a time and water given freely, recovery is usually rapid 
and complete. If the bowels are not cleaned out and food is 
continued, a fatal termination is not uncommon and recovery is, in 
any event, slow. 

Etiology. — The most reasonable explanation as to the etiology of 
these cases is that a bacterial infection of the meconium, through 
either the mouth or anus, takes place within the first twenty-four 
or forty-eight hours after birth; that on account of the incomplete 
evacuation of the intestines the toxic products formed in the 
meconium as the result of this infection are absorbed into the cir- 
culation and that these toxic products cause the symptoms. 
Corroborative evidence in favor of this conception is that, as the 
meconium is made up of protein, the products of bacterial action in 
it must necessarily be putrefactive in character and, therefore, 
toxic. It is a well-known fact, moreover, that cyanosis may be 
enterogenous in origin. It may be asked why this symptom- 
complex is not merely a manifestation of septic infection, that is, 
of the entrance of bacteria into the circulation. It is impossible to 
state positively that this is not the case, because no blood cultures 
have been made in these patients. The early onset of the symp- 
toms, the absence of any nidus of infection and the absence of 
other signs of sepsis, such as hemorrhages, marked jaundice and 
boils, make it improbable, while the rapid and complete recovery 
after the evacuation of the bowels seems sufficient to exclude it. 
It may also be asked why it is not simply a manifestation of starva- 
tion, analogous to the so-called " inanition fever." The answer is 
that it occurs both in babies that have not been fed and in those 
that have been, and that the withdrawal of food in connection 
with the evacuation of the bowels relieves it. 

Diagnosis. — The diseases for which this condition is most 



288 DISEASES OF NUTRITION 

likely to be mistaken are cerebral hemorrhage as the result of 
injury at birth, meningitis, hemorrhagic disease of the new-born 
and septic infection of the new-born. The diagnosis from septic 
infection of the new-born is the most difficult. The symptoms ap- 
pear earlier, as a rule, than do those of septic infection and the 
temperature is usually lower than in sepsis. There is no local 
nidus of infection, and marked general and local symptoms of 
infection, such as hemorrhages, deep jaundice and furuncles, are 
absent. There is a tendency to constipation and the stools are 
usually meconium-like in character. In many instances it is, 
however, impossible to make a positive diagnosis without the 
therapeutic test of free catharsis. Hemorrhagic disease of the 
new-born can be excluded on the absence of hemorrhages. Men- 
ingitis is extremely rare at this age and, when it occurs, it is a 
part of a general septic infection. There is almost invariably 
bulging of the anterior fontanelle in meningitis and usually when 
there is a cerebral hemorrhage. There are usually symptoms of 
focal irritation in hemorrhage and often blood in the nose and 
nasopharynx, while in both cerebral hemorrhage and meningitis 
there is likely to be spasm of the extremities and exaggeration of the 
knee-jerks. These latter symptoms, as well as other symptoms of 
cerebral irritation, may, however, also be present in intestinal 
toxemia. A lumbar puncture will settle the diagnosis at once in a 
doubtful case. 

Prognosis. — The prognosis is a grave one in all but the mild 
cases, unless the condition is properly treated. If the bowels are 
thoroughly cleaned out at once and food stopped for a time, re- 
covery is usually rapid. 

Treatment. — The treatment consists in the administration of one 
or two teaspoonfuls of castor oil, the withdrawal of food for from 
twelve to twenty-four hours and the feeding of water or water 
sweetened with saccharin. It is also well to irrigate the bowels in 
the beginning. Bromide or stimulants, such as strychnia or 
caffein, may be used, if necessary. The best food, after the period 
of starvation, is human milk, plain or diluted, according to the 
individual baby's condition. Next to this, a mixture of cow's milk, 
low in fat, high in milk sugar and with a moderate amount of 
proteins, part of these preferably in the form of the whey proteins. 
A mixture containing 0.50% of fat, 5% of milk sugar, 0.50% of 
whey protein and 0.25% of casein would be a suitable one. It is 
important to give a high percentage of milk, sugar in order to 
change the bacterial activity from the proteolytic to the fermenta- 
tive type. 



AND INFANT FEEDING 289 



CHAPTER XXV 
INFECTIOUS DIARRHEA 

The border line between indigestion with fermentation and 
infectious diarrhea is necessarily a very indefinite one. The 
symptoms in severe cases of indigestion with fermentation differ 
but little from those in mild cases of infectious diarrhea. In both 
instances toxic substances, resulting from bacterial growth, are 
absorbed into the circulation and cause similar symptoms and 
pathological changes. In indigestion with fermentation, however, 
the bacteria do not enter the intestinal wall. The local lesions are, 
therefore, relatively insignificant. In infectious diarrhea, on the 
other hand, the bacteria do enter the intestinal wall and produce 
definite lesions of the wall. These lesions may or may not be 
severe. It is probable that bacteria very seldom pass through the 
intestinal wall and enter the circulation in indigestion with fer- 
mentation. It is probable that they often pass through the wall 
into the circulation in infectious diarrhea. In indigestion with 
fermentation the seat of bacterial activity is primarily and almost 
exclusively in the intestinal contents, while in infectious diarrhea 
it is primarily in the intestinal wall itself. In indigestion with 
fermentation bacteria are the secondary invaders of an abnormal 
intestinal content, while in infectious diarrhea they are the primary 
cause of the disease. These distinctions must not, however, be 
regarded as absolute. They are, nevertheless, definite enough to 
serve as a basis for classification and for treatment. 

Etiology. — Infectious diarrhea is more common in hot weather 
than at other times of the year. The action of heat in the produc- 
tion of the disease is due mainly to the lowering of the general 
resistance to infection which it produces. It presumably also 
favors the development outside of the body of the microorganisms 
which are found in this disease. Microorganisms are, however, the 
primary cause of infectious diarrhea. The microorganisms which 
produce this disease are of several different types. They may be 
divided roughly into three main classes: 

a. The dysentery bacillus in all its forms. 

b. The gas bacillus and similar organisms. 

c. Other organisms, of which the most important are strepto- 

cocci, the colon bacillus and the bacillus pyocyaneus. 



290 DISEASES OF NUTRITION 

The symptoms produced by these different types of organisms 
are practically identical. It is usually impossible to determine 
from them which type of organism is causing the disturbance. 

Pathology. — The pathological lesions of the intestine are very 
varied. There may be only a catarrhal inflammation. In other 
cases there are also superficial ulcerations. In others there is 
hyperplasia of the solitary follicles and Peyer's patches. In many 
instances ulceration takes the place of the hyperplasia of these 
structures. In still others a pseudo-membrane is formed, which 
may involve considerable areas. The pathological lesions are 
usually limited to the large intestine and the last two or three feet 
of the small intestine. They are ordinarily most marked in the 
large intestine. The severity of the symptoms does not always 
coincide with the severity of the intestinal lesions. In general, 
however, the symptoms are most marked in the cases in which the 
lesions are the most serious. 

There is almost invariably a hyperplasia of the mesenteric 
lymph nodes. This almost never, however, goes on to suppuration. 
There are always more or less marked degenerative changes in the 
parenchymatous organs, especially in the liver and kidneys. True 
inflammation of the kidneys is, however, uncommon. Secondary 
infections of other organs, such as the middle ears and lungs, by 
other organisms as the result of the general weakened resistance, are 
not infrequent. 

Symptomatology. — The onset of infectious diarrhea is usually 
acute. It may be preceded for a few days by symptoms of indiges- 
tion, but ordinarily there are no premonitory symptoms. The 
first symptom in most cases is diarrhea. The first stools are made 
up of fecal matter. Mucus and blood soon appear, however, and 
after a few hours or a day or two, the stools are composed almost 
entirely of mucus and blood. Pus is seldom visible macroscopically 
until several days after the onset and, in many instances, it is 
never seen. It can, however, almost always be found with the 
microscope. Membrane is also present in the severest cases. The 
mucus is often stained green or brown. The odor of the stools, 
when they are made up chiefly of mucus and blood, is very slight, 
but sometimes resembles that of wet hay. When the stools contain 
much pus or membrane, as the result of deep ulcerative or gan- 
grenous processes in the intestine, the odor is putrefactive or 
gangrenous. The reaction of the stools is variable, but in most 
instances it is somewhat alkaline. The number of stools is large, 
twelve, twenty-four, or even more, in twenty-four hours. The 
stools are usually small, being often merely a stain of blood and 



AND INFANT FEEDING 291 

mucus. In a general way, the. larger the number of stools, the 
smaller are the individual stools. 

Pain in the abdomen and tenesmus are early, marked and severe 
symptoms. Tenesmus is especially troublesome and annoying and 
often keeps the baby restless and disturbed and prevents it from 
getting the proper amount of sleep. Prolapse of the rectum is not 
at all infrequent as the result of the straining. 

Vomiting is a rather infrequent symptom and is seldom trouble- 
some. The appetite is usually much impaired and there is not 
infrequently the greatest distaste for food of any sort. 

The abdomen is sometimes distended, but in the vast majority 
of instances is much sunken. There is almost never any spasm of 
the abdominal muscles. There is sometimes tenderness over the 
course of the colon, but this is unusual. There is usually no en- 
largement of either the liver or of the spleen. Slight enlargement 
of the spleen is, however, not very uncommon. In some instances 
the liver becomes very large and this enlargement may develop 
very rapidly. The liver will sometimes enlarge enough in three or 
four days to reach well below the navel and to the anterior superior 
spine. 

The temperature is always elevated in infectious diarrhea. It is 
usually only moderate, 100° F. to 102° F., but may be several 
degrees higher. It is more likely to be high in the beginning than 
later. The temperature is usually a fairly constant one without 
marked intermissions or remissions. It lasts throughout the active 
stage of the disease. 

The symptoms are, however, not always so characteristic. The 
number of stools may be but little increased, mucus and blood may 
be scanty, or even wanting, and tenesmus absent. The symptoms 
may be, in fact, precisely like those of severe simple indigestion 
or of indigestion with fermentation. In such instances the con- 
tinued temperature is the most suggestive symptom. The real 
condition can only be recognized in such instances, however, by a 
bacteriological examination of the stools. 

The blood almost always shows a moderate polynuclear leuco- 
cytosis, usually somewhere in the neighborhood of 20,000. It may, 
however, be much higher. In the severest cases in which the toxe- 
mia is extreme and the system is unable to react, there may be no 
leucocytosis or even a leucopenia. 

The urine is almost invariably diminished as the result of the 
loss of fluid through the bowels and the diminution in the intake. 
It not infrequently shows the evidences of acute degeneration of 
the kidneys. Acute inflammation of the kidneys is very unusual. 



292 DISEASES OF NUTRITION 

The urine rarely contains sugar unless the toxemia is extreme or 
very large amounts of sugar are being ingested. 

In the most severe and fatal cases, certain symptoms, such as 
uncontrollable vomiting, marked prostration and hyperpyrexia, 
presumably due largely to toxic absorption, develop. These 
symptoms may also develop in the course of indigestion with 
fermentation. They will be discussed more in detail later and the 
treatment for them described at the same time. 

It is impossible to determine from the symptoms what form of 
organism is the cause of the disease in the individual case. There is 
nothing about the stools which will aid in the differentiation except, 
in rare instances, the peculiar green color caused by the bacillus 
pyocyaneus. If the green color is produced by this organism, it 
will disappear when nitric acid is added to the stool. If it is due to 
bile, the characteristic color of Gmelin's test will appear when 
nitric acid is added. The microscopic examination of the stools is 
of little assistance in differentiating the various types unless the 
streptococcus is the cause, in which case it is usually present in 
large numbers and easily recognized. The presence or absence of 
the gas bacillus can be determined in from eighteen hours to 
twenty-four hours, or even less, by the following method. 

This method is a simple one, which can be easily carried out by 
anyone. A small portion of' the stool is added to a test tube of 
milk. The infected tube is then gradually brought to the boiling 
point of water in a water-bath and kept there for three minutes. 
In this way, all the bacteria not in the spore state are killed and the 
development of whatever spores may be present into vegetative 
cells is unrestrained by the presence of non-spore-forming or- 
ganisms. The tube is then incubated at body temperature for 
from eighteen to twenty-four hours. When the gas bacillus is 
present, the casein is largely dissolved (usually at least 80%) ; the 
residual casein is somewhat pinkish in color and filled with holes; 
and the odor of the culture is much like that of rancid butter, as the 
result of the formation of butyric acid by the gas bacillus. Gram- 
stained preparations made from the milk show rather thick, short, 
Gram-positive bacilli, with slightly rounded ends. The fermenta- 
tion is more easily observed if the milk, after being boiled, is put 
in a sterile fermentation tube. " Pseudo-reactions' ' may occur 
in which there is some liquefaction of the casein, but the shotted 
appearance of the residual casein is absent and there is no odor of 
butyric acid. 1 It must be remembered, however, in interpreting 

1 See Kendall and Smith: Boston Medical and Surgical Journal, 1910> 
Vol. clxiii, 578. 



AND INFANT FEEDING 293 

the results of this test, that the presence of a few gas bacilli does 
not necessarily prove that they are the cause of the disease. There 
is, unfortunately, no method for determining the presence or ab- 
sence of dysentery bacilli that does not require special media and 
a fairly well equipped laboratory. 

Diagnosis. — The only disease with which a typical case of 
infectious diarrhea is likely to be confused is intussusception. It is, 
however, usually not difficult to differentiate between these two 
conditions. Intussusception begins acutely with pain in the 
abdomen and evidences of shock, the stools of mucus and blood 
not appearing until later. The onset of infectious diarrhea is less 
acute, pain is usually not present, or, if so, it is slight, and there are 
no symptoms of shock, while the stools of mucus and blood appear 
almost at once. The stools contain no fecal matter in intussuscep- 
tion, while they usually contain some in infectious diarrhea. Fever 
is common to both diseases, but is usually higher in infectious 
diarrhea than in intussusception. The abdomen is almost always 
sunken in infectious diarrhea, but likely to be somewhat distended 
in intussusception. There is never any muscular spasm in infec- 
tious diarrhea, usually some in intussusception. There may be 
abdominal tenderness in both conditions. It is seldom marked in 
either, however, and is not of importance in the differential diagno- 
sis. There is never a tumor in the abdomen or rectum in infectious 
diarrhea, while there often is one in intussusception. The absence 
of a tumor does not, however, rule out intussusception. Both 
conditions are usually, but not always, accompanied by a leucocy- 
tosis. 

Simple indigestion and indigestion with fermentation are not 
likely to be mistaken for infectious diarrhea. Mild cases of in- 
fectious diarrhea in which the number of stools is not very large and 
in which there is no blood and relatively little mucus in the stools 
are very likely, on the other hand, to be mistaken for indigestion 
with fermentation. Fever, abdominal discomfort, anorexia, wast- 
ing and symptoms of toxic absorption are common to both condi- 
tions. These symptoms differ only in degree in the two diseases 
and may be more marked in indigestion with fermentation than in 
mild cases of infectious diarrhea. It is often very difficult to differ- 
entiate between them and it is not infrequently impossible to 
make a positive diagnosis. The most important single symptom 
in the diagnosis is probably the temperature curve, the elevation of 
temperature in indigestion with fermentation being ordinarily 
either very slight or high and of short duration, while in infectious 
diarrhea, although usually not very high, it is constant and con- 



294 DISEASES OF NUTRITION 

tinuous. In many instances a positive diagnosis can only be made 
by a bacteriological examination of the stools. An agglutination 
reaction is usually present in infectious diarrhea by the end of the 
first week or a little later when the disease is caused by the bacillus 
of dysentery. This reaction is, however, of but little practical 
importance. 

When the temperature is high and the symptoms of cerebral 
irritation are marked and develop before the appearance of the 
characteristic stools, as they sometimes do, the disease may be 
mistaken for some form of meningitis. A careful analysis of the 
symptoms and physical signs will, however, usually make the 
diagnosis plain. A lumbar puncture will settle it at once. 

Prognosis. — Infectious diarrhea in infancy is always a serious 
disease. The prognosis should always be a guarded one. It is 
impossible to know in the beginning what the result is to be. 
Death may occur in three or four days, but most often takes place 
during the second week of the disease. It may be delayed, however, 
for several weeks. Improvement usually begins, in the cases which 
recover, at the end of the first or during the second week. It may 
be delayed for several weeks. Recovery is usually slow and likely 
to be interrupted by relapses. In some instances the disease runs 
into a chronic form which may last for many weeks. Most of these 
cases eventually die, but some recover. 

Symptoms which render the prognosis more serious are high 
fever, the presence of much blood in the stools and the appearance 
of symptoms of marked toxic absorption, such as persistent vomit- 
ing, marked restlessness and convulsions. The presence of albumin 
and other evidences of degeneration of the kidney in the urine are 
not of especially bad prognostic import. 

Treatment. — The first thing to be done in infectious diarrhea is 
to thoroughly clean out the intestinal tract. The best drug for this 
purpose is castor oil. It works quickly, thoroughly and causes less 
irritation of the intestines than other cathartics. The dose should 
not be less than two teaspoonfuls and may be as much as two 
tablespoonfuls. It should be given plain. Castor oil should be 
tried first, even if the baby is vomiting, because it is often retained 
when food and water are vomited. If it is vomited, calomel may 
be given in its place. The usual dose is one-tenth of a grain, com- 
bined with one grain of bicarbonate of soda, every half hour 
until 1 or V/2 grains have been given. It is wise to follow it 
with two or three teaspoonfuls of the milk of magnesia in two or 
three hours after the last dose. The treatment should be repeated, 
if the desired results are not obtained. The lower bowel should 



AND INFANT FEEDING 295 

also be irrigated at once with physiological salt solution (approx- 
imately one teaspoonful of salt to a pint of water). 

All food should be stopped for from twelve to twenty-four 
hours. It is not desirable, as a rule, to withhold food longer than 
this. It is necessary, however, to give water freely during this 
period, because, although a baby can bear temporary starvation, it 
cannot get along without water. At least as much water should be 
given as the baby would normally take of liquid in the form of 
food in the given time. The water may be given either warm or 
cool and may be sweetened with saccharin, if desired. There is no 
objection to giving it in the form of weak tea sweetened with 
saccharin, if it is taken better in this way. It should be given 
through a tube, if the baby will not take it otherwise. 

The most important element in the treatment of infectious 
diarrhea is the diet. The character of the diet depends on the 
variety of microorganism which is causing the disease. These 
microorganisms can be divided, as far as the determination of the 
diet to be used is concerned, into two groups: 

1. The various forms of the dysentery bacillus and the other 
organisms, except the gas bacillus, which cause the disease. 

2. The gas bacillus and allied organisms. 

The other organisms, although of many different varieties, are 
grouped with the dysentery bacilli, because as regards their growth 
and the production of toxic substances from protein and carbo- 
hydrate media, they behave in the same way. 

The dysentery bacillus, the colon bacillus and the streptococcus 
belong to the class of facultative bacteria. This class of organisms 
can thrive upon either carbohydrate or protein media. They 
produce harmless products from carbohydrates and toxic sub- 
stances from protein. They act upon and use up the carbohydrate 
material before they attack the protein, when both are present in 
the medium in which they are growing. The products of the 
breaking down of the carbohydrate material have, moreover, when 
produced in sufficient amounts, an inhibitory action on the develop- 
ment of dysentery bacilli and, to a less extent, of streptococci. 

It is evident, therefore, that when infectious diarrhea is caused 
by bacteria of this type, the food should be largely carbohydrate in 
character. In this way the organisms are prevented from forming 
toxic substances and their growth is, to a certain extent, inhibited. 
The prolonged withdrawal of food is also contraindicated, because 
the intestinal contents are then made up entirely of the intestinal 



296 DISEASES OF NUTRITION 

secretions, which are protein in character. Some form of carbo- 
hydrate should, therefore, be given after a few hours. Sugar is 
preferable to starch, because it is much more easily utilized by 
bacteria. Lactose is preferable to the dextrin-maltose preparations, 
because it is more slowly broken down during the processes of 
digestion. Being less readily absorbed, it thus provides a carbo- 
hydrate medium in the intestine for a longer time than the 
dextrin-maltose combinations. It is probable, moreover, that a 
larger proportion of lactic acid is formed from milk sugar than from 
the other sugars, and lactic acid has an inhibitory action on the 
development of the dysentery bacillus. The lactose should be 
given in the form of a 5% or 7% solution in water. It is better to 
give it frequently in small amounts than in larger amounts at 
longer intervals, because in this way a continuous supply of lactose 
is brought to the intestines. The baby should be given at least 
as much of the sugar solution as it would take of food under normal 
conditions. Half as much more is usually advisable. There is 
little or no danger of producing sugar indigestion or glycosuria, if 
no more than this is given. 

After twenty-four, forty-eight or seventy-two hours, as the case 
may be, it is wise to give the milk sugar in barley water. The 
barley water should contain from 0.75% to 1% of starch. The 
starch provides more nourishment and, being still more slowly 
broken up and absorbed, favors still further the prolonged con- 
tinuance of a carbohydrate medium in the intestine. 

It is necessary to add some protein to the food as soon as possible 
in order to neutralize the protein waste of the organism. It should 
be given as soon as there is evidence of improvement of the condi- 
tion. Care must be taken not to give so much as to neutralize the 
action of the carbohydrates. It is usually safe to begin with 
0.50%, increasing the amount 0.25% at a time as fast as possible 
up to about 1.50%. It may be given either in the form of whey 
protein or casein. If it is added in the form of casein, the mixture 
should be boiled in order to prevent the formation of casein curds. 
No fat should be given until convalescence is well established. 

Irrigations of the colon with solutions of lactose or dextrose, 
while theoretically indicated, are of little practical value. 

The microorganisms which cause the disease enter the intestinal 
wall and probably in many instances reach the mesenteric lymph 
nodes and perhaps the general circulation. The available supply 
of glycogen is quickly used up or greatly diminished in illness, 
especially when associated with total or partial starvation, and the 
conditions favorable for the development of toxic substances by 



AND INFANT FEEDING 297 

the bacteria which have left the intestines are thus provided. The 
introduction of dextrose into the circulation would, therefore, 
furnish a carbohydrate instead of a protein medium for the bacteria 
to grow in. The dextrose also provides an immediately utilizable 
supply of energy and spares the body protein. Dextrose infusions 
are, therefore, indicated in severe cases of infectious diarrhea of 
this type and in cases which are not yielding rapidly to treatment. 
The strength of the infusion should be 2.5% of dextrose in normal 
saline solution. Kahlbaum's is the only readily available pure 
dextrose. Three or four ounces of the solution may be given at a 
time and repeated every four to six hours. The administration of 
these infusions should be checked by urinalysis and must cease if 
sugar appears in the urine. 

The gas bacillus and allied organisms grow rapidly in the in- 
testinal tract when there is an excess of utilizable carbohydrate in 
the bowel and at the same time an insufficient number of those 
organisms which form lactic acid from carbohydrates to produce 
enough lactic acid to inhibit their growth, the gas bacillus being 
sensitive to lactic acid. The indications to be followed in the 
treatment of cases of infectious diarrhea caused by the gas bacillus 
are, therefore, to cut down the carbohydrates in the diet and to 
introduce acid producing bacteria into the intestines. These indica- 
tions can be best met by the use of unheated buttermilk or, better, 
of mixtures containing no fat, 3% or 4% of milk sugar and from 
1.50% to 2.50% of protein, ripened with lactic acid forming or- 
ganisms. It is not possible to cut out the sugar entirely, because, 
if this is done, the lactic acid forming organisms will have nothing 
on which to grow. The lactic acid already present in the food ex- 
erts an immediately inhibitory action upon the gas bacillus, while 
the lactic acid forming organisms in it, by keeping up their produc- 
tion of lactic acid, continue this action. They also use up the 
available supply of carbohydrate and thus interfere with the 
growth of the gas bacillus. Lactic acid given by the mouth is much 
less effective, because it is rapidly broken down and absorbed and, 
therefore, does not have a continuous action. Pasteurized butter- 
milk, in which the lactic acid forming organisms are destroyed, is 
less valuable than raw buttermilk for the same reason. 

Cutting down the carbohydrates in the diet and increasing the 
amount of protein in it is sufficient to relieve the condition in mild 
cases. The percentage of fat should also be kept low. Mixtures 
containing from 1% to 1.50% of fat and from 1.50% to 3% of 
protein, and with no more milk sugar than is necessarily added in 
the milk and cream to give the desired percentages of fat and pro- 



298 DISEASES OF NUTRITION 

tein, are suitable ones. It is well to boil them in order to prevent 
the formation of casein curds. 

It is evident that the line of diet which is suitable for one type of 
infectious diarrhea is not only not suitable, but absolutely harmful, 
for the other, and vice versa. It is extremely important, therefore, 
not to make a mistake in the choice. It is unfortunately almost 
impossible to determine at once what form of microorganism is the 
cause in the individual case. The various methods to be used to 
get at the organism at fault have already been detailed. A point 
which is of some assistance in arriving at a tentative conclusion 
until these measures have been carried out is that in a given season 
the vast majority of the cases of infectious diarrhea are due to the 
same organism. If the prevailing organism is known the chances 
are, therefore, that this organism is also the cause in the given case. 
Another method of determining the cause, a method which is 
most unscientific but nevertheless often the only practicable one, 
is to give what seems to be the most rational diet and then observe 
the results. If the temperature begins to come down and the 
patient improves, it is almost certain that the organism causing the 
disease is of the type for which that form of dietetic treatment is 
indicated. If, on the other hand, the temperature remains elevated 
or rises and there is no improvement in the other symptoms, it is 
evident that the causative organism belongs to the other type and 
that the diet must be changed. 

Irrigation of the bowels once or twice in the twenty-four hours is 
a useful procedure. The object of the irrigation is simply to 
cleanse the colon. It is impossible to use astringent solutions 
strong enough to have any appreciable action upon the intestinal 
wall, even if this was desirable, or antiseptic solutions strong 
enough to have any effect upon the pathogenic bacteria without 
running serious risk of poisoning the baby. The irrigating solution 
should, therefore, be some mild, unirritating solution, such as 
physiological salt solution or a 1% solution of boracic acid. The 
irrigation should be given with a soft rubber catheter, No. 25 
French, passed as high as possible into the bowel, with the patient 
lying on the back and the hips elevated. The fluid is then allowed 
to run in from a bag hung not more than two feet above the level of 
the patient. It should be allowed to run in until the abdomen is 
slightly distended, then allowed to run out, and so on, until the 
wash water returns clear. The object of the irrigation being to 
cleanse the colon, enough liquid should be used to do this, whether 
it is much or little. Irrigation should seldom be done more than 
twice in the twenty-four hours. If it depresses or disturbs the 



AND INFANT FEEDING 299 

patient materially, it should be given up, as under these circum- 
stances it does more harm than good. 

In subacute or chronic cases, in which blood and pus persist in 
the stools after the temperature has dropped and the evidences 
of toxemia have disappeared, injections of nitrate of silver are 
sometimes useful and seem to hasten the healing of the bowel. 
They may be used in the acute stage, but, as a rule, do but little 
good at this time. The colon should first be irrigated with sterile 
water in order to cleanse it. Salt solution should not be used, 
because the sodium chloride forms with the silver nitrate an in- 
soluble silver salt which is precipitated and the action of the silver 
solution is consequently diminished. After the bowel has been 
washed out, from six to sixteen ounces, according to the age of the 
baby, of a 2% or 3% solution of the nitrate of silver are allowed to 
run into the colon and the tube then withdrawn. No attempt 
should be made to have the fluid either retained or expelled. This 
procedure seldom causes any marked discomfort in babies. If it 
does, the silver solution may be washed out with salt solution or an 
opium suppository given. The injections should be repeated every 
day or every other day. If there is no evident improvement after 
three or four injections it is useless to continue them. The first 
stools passed after an injection usually contain more blood and 
considerable dirty gray material, consisting of slough from the 
ulcers, intestinal secretions and pus, discolored by the silver 
nitrate. In favorable cases, however, there is marked improve- 
ment in the character of the stools inside of twenty-four 
hours. 

The various so-called intestinal antiseptics are of little or no 
value in the treatment of infectious diarrhea. It is impossible to 
give them in large enough doses to have any effect on the path- 
ogenic bacteria in the intestines without poisoning the baby. If 
they did have any action, it would be exerted on the antagonistic 
as well as on the pathogenic bacteria. Moreover, the bacterial 
flora can be modified better by regulation of the diet than in any 
other way. In addition, it disturbs the patient to take them and 
interferes with the administration of food and water. The salts of 
bismuth are of little value during the acute stage, whether or not 
they are combined with sulphur. During the chronic stage they 
sometimes seem to diminish peristalsis and perhaps promote heal- 
ing. When used, they should be given in doses of from ten to 
twenty grains every two hours. It is safer to use the subcarbonate 
or the milk of bismuth than the subnitrate, because of the danger 
of nitrite poisoning when the subnitrate is used. 



300 DISEASES OF NUTRITION 

There is no serum which is of any value in the treatment of 
infectious diarrhea. 

Pain and tenesmus are often very troublesome symptoms. In- 
jections of two ounces of starch solution of the strength of one 
drachm of starch to one ounce of water, to which are added from 
three to five drops of laudanum, will sometimes control the tenes- 
mus. They are usually expelled, however, before they have had 
time to do any good. It is generally wiser, therefore, to give the 
opium by mouth, if it is necessary to use it at all. It must be 
remembered when giving opium that its action is to diminish 
peristalsis and that if the peristalsis is diminished enough to inter- 
fere with the free emptying of the bowels serious harm will be done. 
Only enough should be given to allay the tenesmus and prevent 
the frequent stools due to excessive peristalsis. The safest form of 
opium to use is paregoric. It may be given in doses of from five to 
twenty drops. Dover's powder, in doses of from one-eighth to one- 
half of a grain, may also be used. It is better to give small doses at 
short intervals than larger doses at longer intervals. The use of 
hot stupes or compresses to the abdomen will, however, often 
relieve the pain and tenesmus and render the use of opium un- 
necessary. 

In some instances it is impossible to induce the infant to take a 
sufficient amount of water or, if it does take it or it is given through 
a tube, it is vomited. In such cases physiological salt solution 
should be given subcutaneously to make up the deficit. From four 
to six ounces may be given at a time and repeated as often as 
necessary. It is useless to give a second injection, however, before 
the first one is absorbed. Salt solution may also be given through 
the bowel by seepage. Considerable amounts can sometimes be 
introduced in this way, even when the baby is having many stools. 

Stimulants are often necessary in infectious diarrhea in infancy, 
as in other acute diseases. There are no special rules to be followed 
in infectious diarrhea. Alcohol is of doubtful value. Strychnia is, 
in general, the most useful, while caffeine and camphor are the 
best quick stimulants. Strychnia may be given in doses of from 
1/1000 to 1/200 of a grain. The dose of the citrate of caffeine by 
mouth for a baby is from one-eighth to one-half of a grain and of 
caffeine-sodium benzoate or salicylate subcutaneously about the 
same. Camphor may be given subcutaneously in oil in doses of one 
or two grains. 

Special Symptoms. — Babies that are seriously ill with either 
indigestion with fermentation or infectious diarrhea are very 
likely to show one or more rather characteristic symptoms or 



AND INFANT FEEDING 301 

groups of symptoms. One of these groups of symptoms almost 
invariably develops toward the end in fatal cases. These symp- 
toms are: 

a. Excessive vomiting. 

b. Hyperpyrexia. 

c. Symptoms of irritation of the central nervous system. 

d. Prostration and collapse. 

It is probable that these symptoms are chiefly manifestations of 
toxemia. How much of the intoxication is due to the absorption 
of bacterial endotoxines and extracellular toxines, how much to the 
absorption of the products of bacterial fermentation in the intes- 
tinal contents, and how much to purely chemical disturbances of 
metabolism, it is impossible to state. It is presumable that the 
loss of water through the bowels also plays a part in their produc- 
tion. 

If, when any of these symptoms appear, there is any doubt as to 
whether the bowels have been thoroughly emptied, it is advisable 
to repeat the initial catharsis and irrigation. It is also advisable, if 
the condition of the nutrition warrants it, to withhold food for 
about twelve hours. This must be done only after due deliberation, 
however, if the cause of the infectious diarrhea is any other or- 
ganism than the gas bacillus. In all of these cases, unless the 
babies are taking and retaining sufficient liquid by mouth, it is 
advisable to give salt solution subcutaneously or by seepage. 

Little can be done for excessive vomiting beyond the general 
measures already detailed, except to withdraw all food entirely and 
wash out the stomach with a solution of bicarbonate of soda of the 
strength of one level teaspoonful to the pint of water. In some 
instances, small amounts of this same solution of bicarbonate of 
soda, of one of the aerated waters or of ginger ale, will be retained 
when food and water are not. The vomitus not infrequently con- 
tains brownish or reddish flecks or streaks as the result of capillary 
hemorrhages into the stomach. This sign is of serious, but not 
necessarily of fatal, import. 

The hyperpyrexia is best treated by the use of cold externally. 
It is very seldom advisable to give the coal tar products to infants 
to reduce the temperature. Sponge baths of equal parts of alcohol 
and water, at 90° F., are usually effective. If they are not, fan 
baths may be tried. Fan baths are given in the following way: 
The baby is stripped and wrapped in cheesecloth. This is then 
wet with water at 100° F. and the baby is fanned. The tempera- 
ture is reduced by the evaporation of the water. The cheesecloth 



302 DISEASES OF NUTRITION 

is wet from time to time as the water evaporates. Babies seldom 
object to this form of bath. If this is ineffectual, the cold pack at 
from 60° F. to 70° F. should be tried. Babies seldom bear tub 
baths well and it is, as a rule, wiser not to use them. 

An ice bag may also be applied to the head. It must not be 
forgotten, however, that a baby's skull is very thin and that the 
effect of the cold is, therefore, greater than in the adult. This is 
especially true when the fontanelle is open. Great care must, 
therefore, be exercised in the use of the ice cap in infancy. 

Lowering the temperature of the liquid used in irrigating also 
aids in reducing the fever. It may be reduced to 100° F. or 95° F. 
and in desperate cases to 90° F. 

The nervous symptoms are very varied. In some instances the 
babies are stupid, comatose or relaxed. In others they show the 
typical picture of coma vigil. Marked restlessness is a very com- 
mon manifestation. Twitching is not uncommon and convulsions 
not very infrequent. In many instances there are marked signs of 
meningeal irritation. The head may be retracted, the pupils 
unequal, the knee-jerks exaggerated, and so on. In fact, the 
picture may be almost exactly that of meningitis, so much so that a 
diagnosis can only be made positively by lumbar puncture. The 
results of this procedure are also sometimes misleading, because the 
cerebrospinal fluid in this condition sometimes shows a slight 
globulin test and a moderate excess of mononuclear cells. The 
pathological condition is presumably one of meningeal irritation or 
serous meningitis. The treatment of these nervous manifestations 
is purely symptomatic. Bromide of soda, in doses of from five to 
ten grains, by mouth, may be given for restlessness and excite- 
ment. It may be combined with one or two grains of chloral 
hydrate. It is ordinarily useless to give drugs by enema in these 
conditions, as they are almost never retained. If the bromide and 
chloral do not control the symptoms, morphine may be given by 
mouth or subcutaneously, in doses of from 1/100 of a grain to 1/32 
of a grain. It is always advisable in giving morphine to infants to 
begin with a very small dose and then increase it, if necessary. 
An ice bag on the head sometimes helps. When the fontanelle is 
full, a lumbar puncture will often give relief. Convulsions should 
be treated in the usual manner. 

There is nothing especially characteristic about the manifesta- 
tions of prostration and collapse in these conditions. They are to 
be treated in the same way that they are when they occur in other 
conditions. It is important to remember, however, that all forms 
of treatment weaken and exhaust the baby. Irrigations must be 



AND INFANT FEEDING 303 

omitted and the baby disturbed as little as possible. It must be 
kept warm and protected in every way. They are likely, however, 
to be associated with a certain amount of vasomotor paralysis and 
lowering of the blood pressure. Alcohol is, therefore, contrain- 
dicated. Adrenalin is of some value under these circumstances, in 
doses of from two to ten minims of the 1-1000 solution, given 
subcutaneously. Its action is much greater when it is given in- 
travenously. Unfortunately, intravenous injection is not an easy 
matter in infancy. It has practically no effect when given by the 
stomach. Strychnia is, in general, the most useful of the stimu- 
lants, while caffeine and camphor are the best quick stimulants. 
Strychnia may be given in doses of from 1/1000 to 1/200 of a grain. 
The dose of the citrate of caffeine by mouth for a baby is from 
one-eighth to one-half a grain, and of caffeine-sodium benzoate or 
salicylate subcutaneously about the same. Camphor may be given 
subcutaneously in oil in doses of from one to two grains. 

CHOLERA INFANTUM 

There can be no doubt as to the existence of the symptom- 
complex which is usually designated by the name " cholera in- 
fantum." It has all the earmarks of an acute, specific, infectious 
disease. Hence it seems rational to classify it under the head of 
infectious diarrhea. No specific microorganism has, however, ever 
been found for the disease. In fact, it is not certain that it is 
caused by any form or forms of microorganisms. It is possible 
that it is merely a peculiar manifestation of some unusual type of 
intoxication or disturbance of metabolism. However that may be, 
the symptom-complex is so striking that it deserves description as a 
separate entity. It is a rare condition. It almost never occurs in 
children over two years of age and never except in hot weather. 

Pathology. — The pathological changes are practically nil. All 
the tissues are drained of their liquid. There are no lesions of the 
intestines beyond the evidences of a desquamative catarrh or a 
moderate hyperemia of the mucous membrane. There may be 
evidences of cerebral hyperemia and occasionally of edema, but 
these are usually wanting. The kidneys show evidences of degen- 
eration, but no changes sufficient to account for the symptoms. 
The other parenchymatous organs also show degenerative changes. 

Symptomatology. — The symptoms are due primarily to the 
action of some toxic substance upon the heart and nervous system, 
the vasomotor nerves of the intestines being especially affected, 
and secondarily, to the draining of fluid from the various organs. 



304 DISEASES OF NUTRITION 

The onset of the disease is usually preceded by some of the 
symptoms of indigestion, but it may develop in an infant ap- 
parently perfectly healthy. The development of the symptoms 
when they once appear is, however, extremely rapid, so rapid, in 
fact, that a baby may be moribund in five or six hours. The first 
symptoms are ordinarily restlessness or prostration with more or 
less abdominal discomfort and a rising temperature. Vomiting 
begins in a few hours and is accompanied or quickly followed by 
profuse diarrhea. The first vomitus and stools are made up of 
whatever happens to be in the stomach and intestines at the time 
of the onset. After that the vomitus and stools are composed al- 
most entirely of serum. The vomitus is often blood stained. The 
stools are large, watery, almost colorless and without odor. The 
reaction is usually acid in the beginning, but quickly becomes 
neutral and then alkaline. Microscopically they show large 
numbers of epithelial cells, a few leucocytes and very many bacte- 
ria. There is sometimes considerable tenesmus, but in most 
instances the sphincters are relaxed and the fluid simply runs out of 
the bowel every few minutes. There is no tenderness in the 
abdomen and no spasm of the abdominal muscles. The abdomen 
is usually sunken. The tongue is dry and red. 

There is very rapid emaciation as the result of the loss of fluid 
from the tissues. The face appears pinched, the eyes sunken, the 
skin dry and the fontanelle depressed. Thirst is a very marked 
and urgent symptom. The secretion of urine is much diminished. 
It is concentrated and highly acid. It usually contains albumin 
and sometimes casts and blood. 

On account of the accumulation of blood in the abdominal 
organs as the result of the vasomotor paralysis of the abdominal 
vessels and the consequent interference with the peripheral circu- 
lation, the extremities become cold and the skin pale and even 
cyanotic. The surface temperature is usually low, but the rectal 
temperature is high, ranging from 103° F. to 104° F. In fatal cases 
it may reach as high as 106° F. or even 108° F. 

The pulse is rapid from the beginning and soon becomes very 
feeble and irregular. The respiration is usually rapid and irreg- 
ular, but at times slow or sighing. It may be of the Cheyne- 
Stokes or Biot types. 

The infant is usually restless at first and whimpers almost con- 
stantly. After a time it becomes listless and stuporous or symp- 
toms of cerebral irritation develop. The head is retracted, the 
extremities are rigid and twitching and convulsions appear. 

Prognosis — The prognosis is a very grave one. It is very 



AND INFANT FEEDING 305 

seldom that a baby recovers from this disease. Death usually 
takes place during the first forty-eight hours after the onset. The 
disease seems to be self-limited, however, and if the baby survives 
for two or three days, it usually recovers. Recovery is ordinarily 
surprisingly rapid when the severity of the illness is taken into 
consideration. On the other hand, the acute symptoms may abate 
and be replaced by those of various types of indigestion. Sclerema 
sometimes develops under these conditions. The babies may even 
then recover, but ordinarily die after a period of malnutrition. 

Treatment. — In such a rapid and fatal disease it is evident that 
treatment, to be of any avail, must be immediate and vigorous. It 
is probable that there is a vasomotor paralysis of the gastrointes- 
tinal vessels. Hence food and drugs introduced into the alimentary 
canal cannot possibly be absorbed. They can do no good and 
undoubtedly may do harm. 

The main indications for treatment are: 1, to empty the stomach 
and bowels of their toxic contents; 2, to supply fluid to the tissues 
which are being so seriously drained; 3, to restore the surface 
circulation; 4, to reduce the temperature; 5, to keep the patient 
alive until the disease has run its course. 

Purgatives act too slowly to be of much use in this disease, and 
the chief reliance must be placed on stomach washing and intestinal 
irrigation. They are of use in the beginning, but do not do good 
after the first few hours. It is useless to expect to supply fluids by 
the mouth. They are almost invariably vomited. Cold, sterile 
water, in small amounts, may be tried, however. The injection of 
physiological salt solution into the cellular tissue is the only method 
of introducing fluid which can be depended upon. It should be 
given freely in doses of from four to eight ounces at a time and 
repeated almost as soon as it is absorbed. This not only supplies 
fluid to the tissues, but assists in eliminating the toxic substances 
from the blood and in restoring the surface circulation. 

Irrigations of cold water tend to restore the surface circulation 
and also to reduce the temperature. The best methods for re- 
storing the surface circulation are rubbing, mustard baths and the 
warm pack. These procedures, however, are not those best fitted 
for the reduction of temperature. For this purpose cold, in the 
form of sponging, fan baths or packs, must be used. In the treat- 
ment of individual patients it is often necessary to determine 
whether it is the internal congestion or the high temperature which 
is doing the more harm, and then to treat the more serious condi- 
tion. The relief of one, however, often aids the other also. 

As food cannot be given, the patient must evidently be kept alive 



306 DISEASES OF NUTRITION 

by stimulation. As drugs given by the mouth are not absorbed, 
this stimulation must be given subcutaneously. The usual stim- 
ulants, strychnia, caffeine and camphor, are to be employed. 
Strychnia may be given in doses of from 1/1000 to 1/200 of a grain, 
subcutaneously. The dose of caffeine-sodium benzoate or sal- 
icylate is from one-eighth to one-half of a grain and that of cam- 
phor, one or two grains. The camphor should be given in oil. 
Atropine is especially useful in these cases. It is possible that it 
has some special action antagonistic to that of the toxic products 
of the disease. It is to be used in doses of from 1/500 to 1/800 of a 
grain, repeated every two or three hours, as necessary. Morphia is 
indicated when the diarrhea and vomiting are extreme or when the 
nervous manifestations are very marked. Doses of 1/100 of a 
grain are usually sufficient. They should be given subcutaneously. 
Care must be taken not to give too much or to continue it too long. 
In case improvement begins, stimulants and water may be given 
by the mouth, and soon after this, small amounts of food. The 
best food to give first in these cases is diluted human milk. It is 
wise to begin with one part of milk and two or three parts of 
water, giving from one-half to one ounce at a feeding. If this is 
tolerated, the strength and the amount at a feeding should be 
increased as rapidly as is possible. There are no very definite 
indications as to what combination of the food elements should be 
most suitable, when human milk cannot be obtained. The only 
thing that is certain is that the food must be a very dilute one. 
Whey is as likely to agree as anything. If this is tolerated, a mix- 
ture containing 0.25% of fat, 5% of milk sugar, 0.75% of whey 
protein and 0.25% of casein may be given next. If this agrees, the 
percentages of fat and casein should be gradually increased. If 
the whey does not agree with the baby, a mixture containing no 
fat, 2% of milk sugar, 0.75% of protein and 0.75% of starch should 
be tried. It is better to boil this mixture in order to prevent the 
formation of large, casein curds. If this mixture is tolerated, the 
percentages of milk sugar and casein should be increased and fat 
added cautiously. 



AND INFANT FEEDING 307 



CHAPTER XXVI 

CONSTIPATION 

Constipation is not a disease. It is a condition in which the 
number of stools is less or the consistency of the stools is greater 
than is normal for the individual at the given time. 

CONSTIPATION IN THE NEW-BORN 

Constipation in the new-born must not be confused with those 
conditions in which the absence of stools is due to congenital 
malformations of the intestine, such as imperforate rectum and 
atresia of the intestine, which mechanically prevent the passage of 
feces. It is ordinarily due at this time to an insufficient intake of 
food, as the result of delay in the secretion of the breast-milk. In 
other instances, in which the supply of breast-milk or of artificial 
food is sufficient, the difficulty seems to be sluggishness of the 
intestinal peristalsis, apparently from lack of use, or an innate 
feebleness of the intestinal musculature. 

CONSTIPATION IN INFANCY 

Etiology. — The etiology of constipation in infancy is a very 
varied one and several factors are often active in the same case. 
The causes of constipation at this age can be divided into several 
classes, each of which can be further subdivided. These classes are 
so different that they must be considered separately. 

General Causes. — These causes, which should, perhaps, be called 
unclassified, are very different in their nature and in their action. 
They should always be thought of, however, in attempting to 
determine the cause of constipation. The first of these causes is 
heredity. The large number of instances in which constipation is 
present in both parents and infants makes it almost certain that 
heredity plays a part in the etiology of constipation in infancy. It 
is probable, however, that this part is a relatively minor one and 
that in most instances the presence of constipation in one or both 
of the parents and their infant is simply a coincidence. 

Insufficiency of the thyroid gland is another cause of constipa- 
tion in infancy which should always be borne in mind. It would, of 



308 DISEASES OF NUTRITION 

course, not be missed in well-marked cases of cretinism, but is 
easily overlooked when the characteristic signs of thyroid insuffi- 
ciency are slight or absent. 

An insufficient secretion of the intestinal glands or of the liver is 
presumably at the bottom of certain cases of constipation in in- 
fancy. It is very difficult, however, to recognize a deficiency in the 
secretion of these organs and to distinguish constipation from this 
cause from that due to minor errors in diet. 

Constipation is sometimes the result of the administration of 
opium, usually in the form of paregoric or " soothing syrup." 
This cause should never be forgotten in those instances in which no 
other evident cause can be determined. It must always be remem- 
bered in this connection, moreover, that the parents may not be 
aware that the baby is getting opium, because the drug may be 
given by a nurse or nursery maid without their knowledge. Con- 
stipation in a baby, otherwise apparently well, which is very quiet 
and which sleeps unusually well, should always suggest opium as its 
cause. 

Mechanical. — The large intestine is relatively longer in com- 
parison to the small intestine in infancy than in later life and its 
mesentery proportionately longer. The sigmoid flexure makes up a 
relatively larger portion of the colon than later in life and its 
mesentery is comparatively long. These anatomical conditions 
render possible the production of bends and kinks of the colon 
which, while they do not obstruct the lumen of the gut entirely, 
hinder the passage of the intestinal contents through it and thus 
mechanically cause constipation. A Jackson's membrane or some 
other slight malformation in the vicinity of the cecum may also 
mechanically interfere with the free passage of the intestinal con- 
tents. So also may peritoneal adhesions, resulting from inflamma- 
tory processes in the past, whether before or after birth. Still 
another mechanical cause of constipation in infancy is congenital 
dilatation of the colon, or Hirschsprung's disease. In this condition 
constipation often alternates with diarrhea. 

Tumors, most often in the pelvis, may also sometimes be the 
cause of constipation in infancy. In rare instances vesical calculi 
may be large enough to mechanically interfere with the passage of 
feces. 

Spasmodic. — Fissure of the anus may, on account of the pain 
which it causes during defecation, result in obstinate constipation. 
The pain attendant on a movement of the bowels not only makes 
the baby put off a movement as long as possible but also causes 
spasmodic contraction of the anal sphincter. Hemorrhoids, al- 



AND INFANT FEEDING 309 

though rare in infancy, may cause constipation in the same way. 
Large, hard stools may also cause spasmodic constipation on 
account of the pain attendant on their passage. This form of 
constipation is, for this reason, often a complication of other types. 
It may persist for a long time after the cause has been removed, 
the baby being afraid to have a movement because of its memory 
of the pain associated with it in the past. In rare instances a 
tonic spasm of the sphincter is the cause of the constipation. The 
etiology of the spasm in these cases is obscure. 

Dietetic. — Abnormalities in the food, either in its quantity or 
quality, make up one of the two most common of the classes of 
the causes of constipation in infancy. 

The most common abnormalities in breast-milk which result 
in constipation are an insufficient amount of milk, a dilute milk and 
a milk low in fat. The cause of the constipation is the same in all. 
The solids of the milk are so completely absorbed that there is not 
sufficient residue left to form the normal amount of feces. In rare 
instances a high percentage of fat in breast-milk is the cause of 
constipation. The explanation is the same as when there is a high 
percentage of fat in artificial foods. 

Constipation follows when an insufficient amount of an artificial 
food is given or when the food is too weak, because the solids of the 
milk are so completely absorbed that there is not sufficient residue 
left to form the normal amount of feces. An artificial food which is 
low in fat, although it contains a sufficient amount of carbohy- 
drates and protein, is also often accompanied by constipation. 
The cause of the constipation in this instance is the fact that the 
carbohydrates and protein are almost entirely absorbed and 
therefore make but a small amount of fecal matter, while a con- 
siderable proportion of the feces is derived from the fat in the 
food. A more common cause of constipation in the artificially-fed 
is an excess of fat in the food. In these instances the fat combines 
with the earthy alkalis to form the so-called "soap stools." These 
stools vary in color from light-yellow to gray. They are sometimes 
large and hard. In other instances they are dry and crumbly, 
resembling, in typical cases, the stools of a dog which has been 
eating bones. An excess of starch in the food may also cause 
constipation. When the constipation is due to this cause, the 
stools are large, brownish, dry and brittle. 

The heating of milk unquestionably predisposes to constipation, 
but only to a slight extent. It is a far less common cause of con- 
stipation than is ordinarily supposed. The boiling, or sterilization, 
of milk has more influence than does the pasteurization of milk, in 



310 DISEASES OF NUTRITION 

fact, the pasteurization of milk at temperatures below 167° F. has 
almost no appreciable influence. 

One of the most common causes of constipation during the 
second year is the abuse of milk. A baby of this age should seldom 
take oyer thirty-two, or at most forty, ounces of milk in twenty- 
four hours. Constipation is very likely to result if more is given. 
/ Other causes of constipation at this time are an insufficient amount 
of cereal, orange juice and cooked fruit. 

Atonic. — Muscular weakness is the other of the two most com- 
mon causes of constipation in infancy. The intestinal muscles are 
always involved, while the abdominal muscles are not infrequently 
weakened at the same time. One of the most common causes of 
weakness of the intestinal musculature is prolonged indigestion, 
especially if associated with fermentation. Rickets is very fre- 
quently associated with atonic constipation. General malnutri- 
tion, anemia and wasting diseases are other common causes of 
weakness of the intestinal muscles. 

Another cause of muscular weakness is lack of exercise. Many 
babies are kept too quiet and not allowed to use their muscles 
sufficiently to keep up their tone. In other instances the constipa- 
tion is due to the facts that the babies have not been trained to have 
a movement of the bowels at a regular time and have not been 
taught to use their muscles in defecation. It must be remembered 
in this connection that constipation in very young babies may be 
due simply to the lack of voluntary effort on their part to empty 
the rectum. In such instances there are no general symptoms of 
constipation and the bowels move immediately if the rectum is 
stimulated in some way, as by the introduction of a suppository. 

A still further cause of what amounts to atonic constipation is 
the continued use of laxative drugs. These get the intestines into 
such bad habits that they do not respond to the normal stimulus. 

Symptoms. — It is very difficult to describe the symptoms of 
constipation in infancy. Constipated babies are often irritable and 
sleepless. They frequently show evidences of general discomfort. 
Their tongues are coated, their breath is foul and they suffer from 
flatulence and colic. All of these symptoms are, however, present 
in other conditions, especially in those which are not infrequently 
the cause of constipation. It is very difficult, therefore, in many 
instances, to determine what symptoms are due to the constipation 
and what to the primary condition. Pain during defecation is 
almost invariably present in the spasmodic form. If the constipa- 
tion is due to trouble low down in the bowel, there are usually no 
general symptoms associated with it. 



AND INFANT FEEDING 311 

Treatment. — The first element in the treatment of constipation 
in infancy is to establish the etiology, that is, to discover the 
cause of the constipation. This demands, in most instances, a very 
careful study of the diet and habits of the infant. Every detail has 
to be gone into. It also involves a careful physical examination 
including, in most instances, a rectal examination. The problem 
can often only be solved by the aid of Roentgenograms taken after 
bismuth meals or bismuth enemata. Abnormalities in the intestine 
interfering with the passage of the intestinal contents can often be 
discovered only in this way. A lack of general symptoms in con- 
nection with the constipation suggests that the trouble is in the 
rectum. If the introduction of a suppository is immediately fol- 
lowed by the passage of a normal stool, the rectum is certainly at 
fault. The general symptoms are most marked when the con- 
stipation is due to disturbance of the digestion in the small intes- 
tine. 

After the cause is discovered, the treatment must be directed to 
its removal. Certain causes, such as heredity, cannot, of course, 
be altered. Others, such as cretinism and the abuse of drugs, can 
be easily and quickly remedied. Time and the growth of the parts 
can alone remedy some of the mechanical conditions, such as the 
long infantile colon and sigmoid flexure. The other mechanical 
conditions demand operative interference. 

When the constipation is due to the pain caused by the passage 
of large, hard stools, measures should be taken to diminish the 
size of these stools and to make them softer by regulation of the 
diet and, if necessary, by the temporary use of mild laxatives. 
When the pain is due to hemorrhoids, they should be removed. 
Fissure of the anus can usually be quickly cured by keeping the 
stools soft and by the application of boracic acid ointment. The 
application of the nitrate of silver stick will help in some cases. 
Stretching of the sphincter is almost never necessary in infancy. 

The treatment of constipation due to errors in the diet is self- 
evident. When the dietetic errors are removed the constipation 
will cease. These errors can be determined in many instances, 
however, only by the most careful study of the diet and by the 
microscopic examination of the stools. 

The chief element in the treatment of the atonic form of con- 
stipation is the relief of the causative condition, whether it be 
rickets, malnutrition or anemia. Another important element in 
these cases is the training of the baby to have a movement at a 
regular time and to use its abdominal muscles. If the condition is 
due to laxative drugs, they must be stopped. 



312 DISEASES OF NUTRITION 

In most instances it is necessary to relieve the symptom, con- 
stipation, while the cause is being removed. The measures to be 
taken to accomplish this depend to a certain extent on the type of 
constipation present. When the constipation is due to muscular 
weakness, massage of the abdomen twice a day for from five to ten 
minutes is often of considerable assistance. It is of less value in 
the other types. Foods which stimulate the intestinal peristalsis 
are also of especial value in this form. Orange juice or prune juice, 
in doses of from one to four tablespoonf uls daily, may be given dur- 
ing the first year and baked apples and prune pulp during the 
second year. It is also allowable in some cases to give a few tea- 
spoonfuls of strained peas, string beans or spinach, or asparagus 
tips, daily, during the last quarter of the second year. Great 
care must be taken, however, not to disturb the digestion by giving 
an excessive amount of fruit and vegetables and thus to increase the 
constipation or to set up a diarrhea. It is rarely advisable to give 
bran, whether in the form of crackers, cookies, or rolls, to babies, 
although bran crackers can sometimes be used with advantage 
toward the end of the second year. 

If the stools are hard and dry, water, best given between the 
feedings, will often be helpful. Finely divided agar agar, in doses 
of from one to three teaspoonfuls daily, will often keep the feces 
moist and also increase their bulk. It should be mixed or cooked 
with the cereals or given in broth. Coarse foods are more likely to 
do harm than good in this form. 

The addition of oatmeal water or jelly to the food of a baby in 
the latter half of the first year, or the substitution of one of these 
for barley water, will sometimes aid in relaxing the bowels. In 
other instances, however, oatmeal has a constipating effect and 
barley water acts as a laxative. The substitution of one of the 
dextrins and maltose mixtures for milk or cane sugar sometimes 
relieves constipation in young babies. The greater the proportion 
of maltose, the greater, in general, is the laxative action. 

If these measures prove ineffectual, it is necessary to move the 
bowels by the administration of drugs by the mouth or by the 
stimulation of the intestine from below. When the cause of the 
constipation is in the rectum, stimulation from below is plainly 
indicated. When the seat of the trouble is higher up or is a more 
general one, it is often very difficult to decide which method to 
adopt. A good general rule is not to use the same method con- 
tinuously. There is less danger of establishing bad habits, if the 
methods are varied. 

There is more danger of making a baby dependent on stimula- 



AND INFANT FEEDING 313 

tion of the rectum to produce a movement than of making it 
dependent on drugs. This is especially true of suppositories. It is 
very easy to educate a baby to think that it cannot have a move- 
ment of the bowels unless it is reminded of it by the introduction of 
a suppository. Great care must be exercised for this reason not to 
establish a bad habit in attempting to train a baby to have a 
movement at a regular time or on its chair. The simplest and 
least irritating type of suppository is a roll of paper dipped in 
sweet oil. Gluten suppositories are less irritating than glycerin 
suppositories. The soap-stick stands midway between them. 

The best and simplest form of enema is that composed of soap 
and water. No more should be given than is sufficient to produce 
the desired result. From two to four ounces is usually enough; 
more may be given if necessary. It is best given with a soft rubber 
ear-syringe. A fountain-syringe may be used, if desired. If the 
stools are hard and dry, an enema of from one-half ounce to one 
ounce of sweet oil, given to be retained, and followed later by a 
suds enema, if necessary, is often very useful. Glycerin enemas are 
inadvisable in the treatment of constipation in infants. 

The simplest laxative for a baby is milk of magnesia. One 
teaspoonful a day is usually sufficient, but more may be given, if 
necessary. It is best to give it all at one dose, preferably at the 
last feeding at night. Babies take it without question, if it is 
mixed with their milk. Most babies are not disturbed by it. In a 
few it causes considerable pain and discomfort and, therefore, has 
to be omitted. Babies very seldom become dependent upon it. 

If milk of magnesia is not well borne, phosphate of soda in doses 
of from ten to sixty grains may be substituted for it. This is also 
best given in the milk. 

During the latter part of the second year, phenolphthalein, in 
doses of from one to three grains is often useful. Cascara sagrada 
in doses of from one-half to one grain, or of from five to thirty drops 
of one of the liquid preparations, may also be used. 

Purgative drugs, such as castor oil and calomel, and to a less 
extent senna, should not be used continuously in the treatment of 
constipation. They are too powerful and have a secondary con- 
stipating action. Olive oil is useful in some cases. It must never 
be forgotten, however, that olive oil is a fat and that in those 
cases in which the constipation is due to an excess of fat in the 
food it will certainly exaggerate the condition. There is also 
danger, moreover, of disturbing the digestion with it. 



SECTION V 
DISEASES OF NUTRITION 

CHAPTER XXVII 
RICKETS 

Rickets is a constitutional disease which is almost certainly due 
to a disturbance of nutrition. All the organs and tissues of the 
body are affected, but the chief lesions are in the bones. These 
lesions are pathognomonic. Their chief characteristic is a local or 
general disturbance of the normal processes of ossification. Rick- 
ets is most common between the sixth and eighteenth months. It 
seldom occurs earlier and very rarely begins after the third year. 
It develops, therefore, at a time when the bones are in process of 
rapid development. 

Pathological Anatomy. — The bones grow in length through the 
formation of bone tissue in the cartilage between the epiphysis and 
diaphysis. They grow in thickness as the result of the growth of 
bone from the inner layers of the periosteum. As the bone in- 
creases in circumference, the medullary canal is enlarged propor- 
tionately by the absorption of the inner layer of bone. Under 
normal conditions these processes progress in regular order and in 
clearly defined lines. In rickets there is an overgrowth of the 
cartilaginous layer between the epiphysis and diaphysis both in 
width and thickness and it is markedly hyperemic. In this area 
the zone of proliferation is much enlarged and the cells are ar- 
ranged irregularly instead of symmetrically, as in normal condi- 
tions. The deposition of lime salts and the amount of calcifica- 
tion is, nevertheless, much less than under normal conditions. The 
epiphyseal centres of ossification are larger, softer and more 
vascular than normal. There is a similar disturbance in the 
subperiosteal formation of the shaft. The outer layers of the 
shaft are thickened, but soft. The medulla of the bone is more 
hyperemic than normal and the inner layers of the bone also 
become softened through lack of lime salts. 

The visible results of these abnormalities in the growth of the 

315 



316 DISEASES OF NUTRITION 

bones are enlargement of the bones at the epiphyseal lines and at 
the centres of ossification and unnatural flexibility of the bones. 
On account of this increased flexibility, deformities and sometimes 
fractures are produced as the result of pressure or weight bearing. 

Etiology. — While there is but little doubt that rickets is due to a 
disturbance of the metabolism, chiefly of calcium and phosphorus, 
and that the bony changes are due to some interference with the 
deposition of lime salts, it is still a fact that the cause of rickets is 
not positively known. Many theories have been advanced, how- 
ever, as to its causation, all of which have a certain amount of 
evidence in their favor. 

Considerable importance has been attached to heredity as a 
predisposing factor in the etiology. It is believed that the pre- 
disposition is transmitted especially through the mother. Siegert * 
is the chief exponent of this theory. It has, however, received but 
little support. 

Another theory is that it is due to improper hygienic surround- 
ings and lack of fresh air and sunlight. Evidence in favor of this 
theory is that it is more common in the city than in the country, 
in the winter than in the summer, in the poor than in the well-to- 
do. It is also apparently more common in this country in those 
races whose new surroundings are most different from those to 
which they were accustomed. The children of a pastoral race are 
most likely to develop it when confined to a city. This is also 
true of wild animals. They never have the disease when free, but 
often develop it when confined in zoological gardens. 2 

The most generally accepted theory is that, other things be- 
ing equal, it is much less common in the breast-fed than in the 
artificially-fed, unless lactation is unduly prolonged. It is also more 
common when the artificial feeding is bad than when it is rational. 

It has also been thought recently that it is infectious in origin. 8 
Certain animal experiments have seemed to give positive results. 
In these experiments a diplococcus was found in the bones of young 
animals which were clinically rachitic. 4 The evidence in favor of 
the infectious origin of the disease is, however, most conclusive. 

Attempts have been made in recent years to prove that some 

1 Siegert: Jahrb. f. Kinderh., 1903, lviii, 929. 

2 Lehnerdt: Ergebn. d. inn. Med. u. Kinderh., 1910, vi, 120. 

3 Oppenheimer and Hagenbach: Burkhardt quoted by Wieland in Bruneg 
and Schwalbe Handbuch der Allgemeine Pathologie und der Pathologischen 
Anatomiedes Kindesalters, Wiesbaden, 1913, ii, pt. I, p. 260. 

4 Morpurgo: Verhandl. d. Deutsch. path. Gesellsch., 1900, iii, 40, Ibid. 1909, 
xiii, 51; Schmorl: Ergebn. d. inn. med. u. Kinderh., 1909, iv, 403; Koch: 
Ztschr. f. Hyg. u. Infectionskr., 1911, lxix, 436. 



AND INFANT FEEDING 317 

of the diseases of metabolism, including rickets, are due to a dis- 
turbance of the function of certain of the glands which have an 
internal secretion. 

They are respectively the thyroid, parathyroid, adrenal and 
thymus glands (Mettenheimer, 1 Matti, 2 Howland, and his asso- 
ciates 3 repeated the experiments on animals, using suitable con- 
trols, and were unable to produce rickets in any animals in which 
the thymus was removed. It seems, therefore, as if the work upon 
which was based the evidence that the thymus had some etiological 
relation to rickets, was not properly carried out. 

Kassowitz 4 believes that the increased vascularity of the bone 
marrow and epiphyses is the principal feature of rickets and ex- 
plains the abnormally wide zone of growth, and that these blood 
vessels erode the bone. 

Artificial Rickets in Animals. — Most investigators who have 
undertaken to reproduce rickets in animals have assumed that it 
is due to some disturbance in the calcium metabolism. They have 
assumed that it results from a calcium starvation because of too 
little calcium in the food, that there is sufficient calcium in the 
food but for some reason it is not absorbed in normal amounts, or 
finally that it is absorbed in normal amounts but the bones are 
unable to utilize it in the normal manner. Experiments on animals 
have given varying results. In most instances when animals have 
been fed on a food deficient in calcium, on an acid food or on a 
combination of the two, they have become clinically rachitic 5 with 
enlarged epiphyses. The microscopic appearance of such bones 
differs from that in true rickets in that the zone of proliferation is 
much narrower. Miwa and Stoeltzner's 6 experiments lead them 
to differentiate this condition from true rickets in infants and they 
give it the name of pseudorachitic osteoporosis. The bones from 
such animals have a very low ash and calcium content, but have 
not lost relatively as much magnesium as the bones in true rickets. 
In the former the loss of phosphoric acid goes hand in hand with 
the loss of calcium, while in the latter there is relatively less phos- 
phorus lost than calcium. 

Aron and Sebauer 7 produced artificial rickets in dogs without 
changing the calcium content in the muscles, although that in the 

1 Quoted by E. Wieland, loc. cit. 

2 Matti: Mitt, aims den Grenzgebieten der Med. u. Chir., 1911-12, xxiv, 665. 
' Reported at Stockbridge, 1914, Am. Ped. Soc. 

4 Kassowitz: Jahrb. f. Kinderh., 1912, N. F. lxxvi, 369. 
6 Schmorl: Ergebn. d. inn. Med. u. Kinderh., 1909, iv, 403. 

6 Miwa and Stoeltzner: Beitr. z. path. Anat. u. allg. Path., 1898, xxiv, 578. 

7 Aron and Sebauer: Biochem: Zeitschr., 1908, viii, I. 



318 DISEASES OF NUTRITION 

bones was greatly diminished. This fact will be referred to again 
in the discussion of human rickets. 

Calcium Metabolism in Health and in Rickets. 1 — The skeleton 
of a newly-born baby, weighing 2,600 grams, weighs 445 grams, 
the muscles 625 grams, the skin 379 grams, and the brain 342 
grams. 2 The dried bones of a newly-born infant contain 60% 
to 65% of ash and 40% to 45% of organic material. The amount 
of ash in the bone varies from birth onward. At first the ash 
increases, but during the second year it decreases to about 55%, 
with a corresponding increase in the organic material. At the 
end of the second year the ash again begins to increase until it 
reaches the 68% of the dried bone substance found in adults. 3 
The calcium oxide is distributed through the body in the following 
manner: muscles 0.03%, skin 0.02%, brain 0.107% and skeleton 
5.4%. There is in the whole body 25 grams of CaO. 4 Camerer 
and Soldner 5 give 1.019 grams to every 100 grams of body weight 
as the average amount of CaO in the newly-born. 

Schabad 6 says that the weight of the skeleton is 16% of the 
total body weight during the first year of life. The calcium con- 
tent of the skeleton is 1.25% of the body weight and 7.7% of the 
skeletal weight. The largest deposit of calcium takes place during 
the period of greatest growth, viz., in the breast-fed infant between 
the second and fourth months and in the bottle-fed infant between 
the second and sixth months. 

Calcium in Milk. — Examination of the metabolism experiments 
in rickets shows that in artificial feeding the amount of calcium 
usually given is so large that there is no possibility of a calcium 
deficit in the food. When the infant is fed with human milk, the 
situation is different. The percentage of calcium may vary from 
0.03% to 0.08%, the lower limit of that taken by healthy nurslings 
being about 0.034%, while the average is about 0.044%. The 
calcium content of milk decreases as lactation progresses from 
0.045% to 0.031%. 7 It is clear, therefore, that the milk secreted in 
early lactation will have a higher percentage than that in later 
lactation. This does not necessarily mean that the total daily 

1 Much of this section is taken from Orgler: Ergeb. d. inn. Med. u. Kinderh., 
1912, viii, 142. 

2 Vierordt: Gerhardt's Handb. d. Kinderh., 1877, i, 53. 

3 Schabad: Arch. f. Kinderh., 1909-10, lii, 47. 

4 Brubacher: Zeitschr. f. Biol., 1890, xxvii, 517. 

5 Camerer and Soldner : Zeitschr. f . Biol., xxxix, 173; xl, 1900, 529; 1902, xliii, 1. 

6 Schabad: Arch. f. Kinderh., 1910, liii, 380. 

7 Bahrdt and Edelstein: Jahrb. f. Kinderh., 1910, lxxii, 16 (Suppl.); Schabad: 
Jahrb. f. Kinderh., 1911, lxxiv, 511. 



AND INFANT FEEDING 319 

amount of calcium received will be any different in early and late 
lactation, because in early lactation less milk is secreted than in 
later lactation. This may explain the fact why one nursling devel- 
oped rickets on 0.04% of CaO. 

Dibbelt * reports that he was able to increase the CaO content 
in human milk by giving Ca to the mother, but no subsequent 
investigators have been able to confirm these results. 2 

Calcium Requirements of Infants. — Orgler concludes after 
a long discussion that unless an infant absorbs at least 0.13 grams 
of CaO per day it will become rachitic. It must be borne in 
mind, however, that Tobler and Noll's 3 baby absorbed only 
0.054 grams and yet did not acquire rickets. The average of the 
amount of calcium taken by all infants is between 0.17 grams and 
0.18 grams. The normal infant takes as a rule only as much 
calcium from human milk as it requires for growth. 4 It must be 
remembered in this connection, however, that the amount of some 
of the other food components may be so disproportionately high 
(for example fat) that the infant receives so many calories in a 
concentrated food that it does not take enough in amount to give 
it the amount of calcium it requires, even though the percentage 
of calcium is within normal limits. Infants have been reported to 
become rachitic receiving 0.088% CaO. 

Calcium Metabolism. — The methods of quantitating the salts 
in the food and excretions of the body are very difficult and certain 
authorities say that they are all unreliable with the exception 
of Macrudden's method for Calcium. Since there is so much 
doubt as to the accuracy of the methods used in obtaining the 
following information, it must all be considered with the inac- 
curacies well in mind. 

Calcium is in the milk principally in organic combination. Both 
organic and inorganic calcium may be absorbed by the body. The 
calcium in the food goes into solution in the stomach. From 5% to 
10% of it appears in the urine after absorption, while the rest of the 
calcium that is not retained in the body is excreted through the 
feces. This may pass directly through the intestines into the 
feces or indirectly, viz. : it may be absorbed in the small intestine 
and excreted again in the large intestine. 5 Most of the calcium 

1 Dibbelt: Ziegler's Beitr., 1910, xlviii, 147. 

2 Bahrdtand Edelstein: Jahrb. f. Kinderh., 1910, Ixxii, 16 (Suppl.); Schabad: 
Jahrb. f. Kinderh., 1911, lxxiv, 511. 

» Tobler and Noll: Monatsschr. f. Kinderh., 1910-11, ix, 210. 

4 Aron: Biochem. Zeitschr., 1908, xii, 28. 

5 First shown in dogs by E. Voit: Zeitschr. f. Biol., 1880, xvi, 55. 



320 



DISEASES OF NUTRITION 



excreted in the urine is combined with phosphoric acid, but a small 
amount is combined with carbonic, sulphuric and uric acids. 1 

The most striking fact in the chemistry of rickets is that the bones 
in rickets as compared to the normal have a diminished amount of 
calcium and phosphorus and an increased amount of water. The 
following table taken from Orgler 2 illustrates this fact very well : 

This table was compiled by Orgler from Schabad: 3 

TABLE 49 



Normal 
Ribs Occiput 



Rachitis 
Ribs Occiput 



Water 

Organic substances 

Ash 

CaO 

P 2 5 



14.4-329 

26.9-39.1 

40.2-46.6 

21.7-25.3 

12.3-18.9 



13.0-16.1 
32.2-36.5 
47.6-51.7 
26.3-27.9 
18.1-20.7 



42.4-66.4 

20.7-27.4 

7.9-32.0 

4.2-16.8 

3.3-12.8 



29.0-35.9 
26.1-31.6 
34.3-40.6 
19.0-24.1 
13.7-17.8 



These changes are less marked in mild than in severe rickets. 
The influence of the other food components on the calcium 
metabolism. — Proteins. — There are very few experiments that 
have any bearing on the subject, but those that can be utilized 4 
seem to show that the proteins have no influence on the calcium 
retention. 

Fat. — According to some writers fat has a marked influence on 
the calcium metabolism, as increased amounts cause a negative 
calcium balance. 5 The following table from Orgler serves to 
illustrate this point: 

TABLE 50 





I. Groeger 
(a) skim milk 
N CaO 


(Rothberg 6 ) 

(6) cream 

N CaO 


Steinitz II, 7 
milk cream 
CaO CaO 


Food 

Urine 

Feces 


2.963 
2.499 
0.315 


0.975 
0.020 
0.818 


3.400 
2.625 
0.381 


0.927 

0.0 

1.125 


0.398 
0.005 
0.355 


0.378 

0.0 

0.412 


Balance .... 


+0.149 


+0.137 


+0.394 


—0.198 


+0.038 


—0.034 



1 Albu-Neuberg: Mineralstoffwechsel, Berlin, 1906, 116. 

2 Made up from figures of Schabad: Arch. f. Kinderh., 1909-1910, Hi, 47, 63; 
1910, liii, 380, 1910, liv, 83. 

3 Schabad: Zur Bedeutung des Kalkes in der Pathologie der Rachitis: Arch, 
f. Kinderh., 1910, lii, 47 and 63; 1910, liii, 380; 1910, liv, 83. 

4 Tada: Monatsschr. f. Kinderh., 1905-06, iv, 118. 

5 Freund: Jahrb. f. Kinderh., 1905, lxi, 36. 

6 Rothberg: Jahrb. f . Kinderh., 1907, lxvi, 69. 

7 Steinitz: Jahrb. f. Kinderh., 1903, Mi, 689. 



AND INFANT FEEDING 



321 



In other instances increasing amounts of fat in the food have 
no influence on the Ca metabolism, as is shown by the following 
work of Freund: * 

TABLE 51 





Arndt 

5 /i2 milk 

Water 

CaO 


Whole 
milk 
CaO 


Steinitz 

}/2 milk 

CaO 


Cream 
CaO 


Food 

Urine 


0.478 

0.0 

0.409 


0.857 
0.022 
0.467 


0.414 
0.387 


0.314 


Feces 


0.216 






Balance 


+0.069 


+0.368 


+0.027 


+0.098 







Carbohydrates. — Up to recently there were no experiments free 
from error showing the influence of carbohydrate on the retention 
of calcium. In 1913 Howland 2 reported the results of a study of 
the calcium metabolism as it was influenced by carbohydrates. A 
milk mixture without any carbohydrate was followed by a very 
slight positive or by a negative balance of calcium. When the 
same mixture was given with carbohydrate added, even though the 
carbohydrate was a small quantity of cereal, a positive calcium 
balance often resulted, and when sugar was given the calcium 
balance was practically always positive. This work seems to 
indicate that carbohydrate has a very marked influence on the 
retention of calcium. There are no figures to show what effect an 
excess of carbohydrate has on the calcium metabolism. 

Salts. — There are no studies to show the effect of the sodium or 
potassium salts on the retention of calcium in infants. The effect 
of an absence of organic material in the food, as in fasting, is also 
unknown. 

Cronheim and Muller 3 reported that boiling milk influenced 
the calcium retention, but Arndt, 4 who used better methods, 
showed that boiling had no effect on the retention of calcium. 

During the early stage of florid rickets 5 the calcium balance is 
either diminished or negative. This disturbance in the calcium 
metabolism may be present some time before the appearance of 

1 Freund: loc. cit. 

2 Reported before the Am. Pediatric Soc, Washington meeting, May, 1913. 
Not yet published. 

3 Cronheim and Muller: Jahrb. f. Kinderh., 1903, lvii, 45. 

4 Quoted by Orgler — loc. cit. 

5 Schabad: Arch. f. Kinderh., 1910, liii, 380. 



322 DISEASES OF NUTRITION 

any of the clinical signs of rickets. 1 As the disease becomes well 
developed, the calcium balance is either below the average or 
within normal limits. When convalescence or cure commences 
there is a greatly increased retention of calcium, which shows itself 
earlier than does clinical improvement. During this period two or 
three times as much calcium is retained as in the normal, and when 
cure is complete the calcium retention again becomes normal. 

The increased excretion of calcium from the body in florid rickets, 
goes on exclusively through the intestines, while at the same time 
there is less calcium than usual excreted through the urine. 2 

Phosphorus metabolism like the calcium metabolism is influenced 
by the kind of food given. 3 There is relatively so much phos- 
phorus excreted that it cannot all come from the bones and pre- 
sumably comes from the nervous system. 4 The relation between 
the urinary and fecal phosphorus in healthy nurslings is 80 :20 and 
in rachitic nurslings 65 :35, while in the healthy bottle-fed infant it 
is 60:40 and the rachitic artificially-fed 40:60. During con- 
valescence from rickets, the total excretion of phosphorus is lower 
than normal, and the relation of the urinary to the fecal phos- 
phorus returns to the normal figures. Calcium is excreted in the 
feces with phosphoric acid or fatty acid, and it is conceivable that 
an increase of either of these substances may increase the calcium 
excretion. 

Analyses of both rachitic and healthy bones show that the com- 
plex salt Ca2(P0 4 )23CaC0 3 is the same in both instances. Potas- 
sium, sodium and chlorine are the same in both. Magnesium 
is increased from 0.50% in the normal bone to 0.53-0.74% in 
rachitic bone. 5 

The muscles in rickets give evidence of the calcium loss from 
the body. They contain less calcium than do normal muscles, 6 the 
amount of the deficiency varying directly with the severity of the 
disease. 

The calcium content of the other organs is not diminished in 
rickets. Pathologically, rachitic muscles show an excessive thin- 
ning of the muscle fibres with loss of striation, accompanied by an 
increase in the number of cell nuclei. These changes are most 
marked in the most severe cases. 

1 Birk and Orgler: Monatsschr. f . Kinderh., 1910-11, ix, 544. 

2 Schabad: Arch. f. Kinderh., 1910, liii, 380; Dibbelt: Verhandl. der 
Deutsch. path. Gesellsch., 1910, xiv, 294. 

3 Albu and Neuberg: loc. cit., p. 144. 

4 Schabad: Arch. f. Kinderh., 1910, liv, 83. 

5 Gassmann: Hoppe-Seyler's Zeitschr. f. Phys. Chem., 1910-1911, lxx, 161. 
6 Aschenheim and Kaumheimer: Monatsschr. f. Kinderh., 1911-12, x, 435. 



AND INFANT FEEDING 323 

Treatment. — What little evidence there is derived from exper- 
iments on animals goes to show that, while a deficiency of calcium 
in the food causes a disturbance in the ossification of the bones, it 
does not produce rickets. It is evident, moreover, from the figures 
which have just been given, that there never is a deficiency of 
calcium in artificial foods, of which cow's milk forms the basis. 
There is, therefore, no justification whatever for giving calcium to 
rachitic babies that are taking cow's milk. It is barely possible, 
but extremely improbable, that a nursing baby may not get enough 
calcium in its food. Judging from the results of animal experi- 
mentation, such a deficiency would not, however, cause rickets. 
Nevertheless, it might be justifiable to give a breast-fed rachitic 
baby some form of calcium. There is no evident reason why one 
form of calcium should not be as useful as another under these 
circumstances. In any event, only a small amount would be 
required. It is probably useless to attempt to increase the calcium 
in the milk by giving calcium to the mother. If rachitic babies are 
taking neither human milk nor cow's milk and are, therefore, not 
getting enough calcium in their food, they should be given one or 
the other. It will then be unnecessary to give them calcium. It is 
possible that a baby that is taking a very rich food may take so 
little of it that it does not get enough calcium. The remedy for 
this condition is to dilute the food so that the baby will take more 
of it, rather than to give calcium. 

There are very few data as to the relation of the other food ele- 
ments to the metabolism of calcium. It is possible that the 
presence of a large excess of fat in the food may, by combining 
with the calcium in the food, interfere with its absorption and, 
therefore, with its retention. The evidence as to this fact is, how- 
ever, inconclusive. There is, on the other hand, a certain amount 
of evidence which goes to show that the addition of a carbohydrate, 
whether sugar or starch, to a food, the basis of which is cow's milk, 
favors the retention of calcium. Variations in the amount of pro- 
tein in the food have no apparent effect on the metabolism of 
calcium, but it must be remembered in this connection that a 
large part of the calcium in milk is in combination with protein, a 
deficiency of which might cause a deficiency of calcium. Neither 
do variations in the amount of sodium and potassium. There are 
no data as to the effect of variations in the amount of the other 
salts. 

Other things being equal, rickets is much less common and much 
less severe in breast-fed than in artificially-fed babies. The best 
food for the rachitic baby is, therefore, good human milk. If this 



324 DISEASES OF NUTRITION 

cannot be obtained, the next best food must be selected. This is, 
necessarily, some form of modified cow's milk. There are no very- 
definite general indications, based on our knowledge of the metabol- 
ism in rickets, as to what the composition of this food should be. 
What little experimental evidence there is, however, suggests that 
it is advisable to avoid high percentages of fat and to give per- 
centages of carbohydrates well up to the normal limits. These 
points should be borne in mind, therefore, in deciding upon the 
composition of the food. They are of but comparatively little 
importance, however, and should be disregarded if they conflict 
with the evidence furnished by the symptoms and stools as to the 
digestive capacity of the individual infant. The chief object in 
the selection of the food for the rachitic baby, as well as for all 
other babies, is to fit the food to the digestive capacity of the 
individual infant at the given time. That is, the composition of 
the food for a rachitic baby should be decided upon in the same 
way as that of any other baby, bearing in mind that perhaps it may 
be advisable to keep the percentage of fat lower and that of the 
carbohydrates higher than would ordinarily be done. 

There has been much discussion as to whether cod-liver oil and 
phosphorus, either alone or in combination, are of advantage in the 
treatment of rickets. It would seem fairly definite, however, from 
the experimental data as to the effect of large amounts of fat in 
the food on the metabolism and retention of calcium, that cod- 
liver oil might not only do no good but perhaps active harm. The 
evidence as to the action of phosphorus, whether alone or in com- 
bination with cod-liver oil, which is summed up briefly below, is 
conflicting. 

Kassowitz 1 first recommended phosphorus in the treatment of 
rachitis. His original prescription, known as phosphorlebertan 
(phosphori 0.01, ol. jecor aselli, ad 250), still holds first place in 
Germany in the treatment of rachitis. Kissel 2 found in his experi- 
ments on animals that phosphorus had absolutely no effect on the 
skeletal system, and concluded that there was no ground for its 
use. Despite this evidence phosphorus continues to be used and 
many experiments have been performed to prove its efficiency. 

Birk 3 and Schabad 4 both concluded that phosphorus in thera- 
peutic doses does not affect the calcium metabolism in healthy 
children. Such children take only as much phosphorus as they 

1 Kassowitz: Ztschr. f. klin. Med., 1883-4, vii, 36. 

2 Kissel: Virchow's Arch, f . path. Anat., 1896, cxliv, 94. 

3 Birk: Monatssehr. f. Kinderh., 1908-09, vii, 450. 

4 Schabad: Ztschr. f. klin. Med., 1909, lxvii, 454. 



AND INFANT FEEDING 325 

need for growth regardless of the amount in the food. In rachitis 
cod-liver oil increases the retention of phosphorus and calcium and 
this action is intensified by the addition of phosphorus to the oil. 1 
The increased retention of calcium starts three to five days after 
giving phosphorus and gradually diminishes until at the end of 
two months it is again normal. This is because of the increased 
absorption and decreased excretion through the urine and feces. 
The question then came up as to whether oils as such in combina- 
tion with phosphorus have a therapeutic action on rachitis. 
Schabad 2 investigated the action of phosphorus, cod-liver oil and 
"sesamol" on the metabolism of calcium, phosphorus, fat and 
nitrogen and found that "sesamol" and phosphorus did not help 
rachitis, while cod-liver oil plus phosphorus increased the retention 
of phosphorus and calcium and the absorption of fat and nitrogen. 
Schabad and Sorochowitsch 3 used lipanin, i. e., olive, a substitute 
for cod-liver oil, which was supposed to be easily absorbed because 
it contained free fatty acids. They concluded from their metab- 
olism experiments that lipanin and olive oil increase the absorption 
of nitrogen and fat but that lipanin has no advantage over olive oil. 
Lipanin does not increase the retention of calcium in rachitis and 
is therefore not as good as cod-liver oil in the treatment of rachitis. 
They say in their most recent article 4 that sometimes phosphorus 
and cod-liver oil does not have a favorable action on the retention 
of calcium in rachitis, especially if the disease is not approaching a 
convalescence. At other times it has a favorable action on the 
calcium retention. They experimented with various other salts 
combined with cod-liver oil and found that a calcium acetate cod- 
liver oil had the most favorable action on rachitis because it con- 
tained much more calcium. Most recently Caroline Towles 5 did a 
series of metabolism experiments in von Pirquet's clinic in Breslau 
and was unable to demonstrate that phosphorus cod-liver oil had 
any action at all on acute rachitis. 

It is very difficult to draw any conclusions from this evidence as 
to the advisability of using cod-liver oil and phosphorus in the 
treatment of rickets. It is probably safe to conclude, however, 
that it is not advisable to give large doses of cod-liver oil or any 
other fat. It is also probably safe to conclude that phosphorus may 
do good and that, at any rate, it does no harm if properly used. If 

1 Schabad: Ztschr. f. klin. Med., 1909, lxviii, 94. 

2 Schabad: Ztschr. f. klin. Med., 1909-10, lxix, 435. 

8 Schabad and Sorochowitsch: Monatsschr. f. Kinderh., 1910-11, ix, 659. 

4 Schabad and Sorochowitsch: Monatsschr. f. Kinderh., 1911-12, x, 12. 

5 Towles: Ztschr. f. Kinderh., 1910-11, i, 346. 



326 DISEASES OF NUTRITION 

phosphorus is used, it is probably best to give it in combination 
with cod-liver oil. The best preparation of phosphorus is phos- 
phorated oil. A minim of this preparation contains about 1/115 of 
a grain of phosphorus. The dose for a baby is from one-half of a 
minim to two minims, two or three times daily. Too much should 
not, however, be expected from it. It is liable to disturb the 
stomach and should be given after food. 

An abundance of fresh air and sunlight is of the greatest impor- 
tance in the treatment of rickets. Everything should be done to 
improve the hygienic surroundings. Massage undoubtedly does 
good. The advantage of salt baths is problematical. Iron should 
be given, if there is anemia. Other treatment can be only symp- 
tomatic. 



AND INFANT FEEDING 327 



CHAPTER XXVIII 

INFANTILE SCURVY 

Scurvy is a constitutional disease due to a disturbance of the 
nutrition. The disturbance of nutrition is the result of some pro- 
longed error in the diet. The error in the diet is in all probability 
the absence or marked diminution of some constituent or con- 
stituents of the food essential for the carrying on of the normal 
metabolic processes and for growth. It is not known exactly what 
these constituents are, but it is very probable that they are of the 
nature of vitamins. The chief characteristic of the disease is a 
tendency to hemorrhage. Infantile scurvy is the same disease as 
scurvy in the adult. Scurvy and rickets, although often asso- 
ciated, are two distinct diseases. 

PATHOLOGICAL ANATOMY 

The bone marrow shows characteristic changes. These are most 
marked at the ends of the diaphyses of the long bones and the 
anterior ends of the ribs. The bone marrow, which is normally 
rich in lymphoid cells, loses its lymphoid character and is con- 
verted into a tissue poor in cellular elements, that contains rela- 
tively few blood vessels. This tissue consists of a homogeneous 
ground substance containing spindle and stellate cells. There is 
still much calcified ground substance, but it has not been converted 
into true bone. As the result of the interference with the normal 
processes of ossification, the cortex of the bones is thinner and more 
brittle than normal and the density of the bone is materially 
diminished at the epiphyseal line. Fractures of the shafts occur 
very readily, therefore, as the result of very slight injuries. These 
occur most often at or near the epiphyseal lines. The epiphyses are 
often loosened and separated. Marked displacement of the 
epiphysis is, however, uncommon because the periosteum usually 
remains intact. 

The periosteum of the long bones is thickened and congested, 
but shows no excess of leucocytes or small round cells. Hem- 
orrhages between the periosteum and the bone are very common 
and may be very extensive. They may break through the perios- 



328 DISEASES OF NUTRITION 

teum into the surrounding tissues. Small hemorrhages in the 
marrow of the bones are also probably not at all uncommon, but 
can hardly be recognized clinically. Subperiosteal hemorrhages 
are much more common in the lower than in the upper extremities. 

Hemorrhages may occur in any of the internal organs. They are 
common in the skin and are found at autopsy in most of the serous 
membranes. They may also occur in the intestinal mucosa. 
Hematuria, without inflammatory changes in the kidney, is com- 
mon. A hemorrhagic condition of the gums is a common symptom 
when the teeth have erupted. It is, however, very uncommon 
before the teeth have appeared. Hemorrhage sometimes takes 
place in the orbit, pushing the eye forward, also under the dura 
or into the joints. 

Hess and Fish 1 have recently made a study of the blood in 
this disease to determine the cause of the hemorrhages. They 
found that the clotting power of the blood in scurvy was, as a 
rule, slightly diminished. This diminution was not, however, 
constant and cannot, therefore, be regarded as an essential mani- 
festation of the disease or sufficient to account for the hemor- 
rhagic tendency so characteristic of it. They found that there 
was no deficiency of calcium or blood-platelets and no excess 
of antithrombin. They then studied the blood vessels by means 
of what they term the "capillary resistance test" and found 
that there was a weakness of the vessel walls in scurvy. This 
weakness is also present in other conditions than scurvy and is, 
therefore, not pathognomonic of it. It seems evident from their 
work, however, that the hemorrhagic tendency in scurvy is due 
to a weakness of the vessel walls rather than to any change in the 
blood. 

ETIOLOGY 

Certain facts are definitely known as to the etiology of scurvy. 
One of them is that it occurs most frequently in the last half of the 
first year and in the first quarter of the second year. More than 
four-fifths of the cases develop during this period and half of them 
between the seventh and tenth months. It has been seen, however, 
in infants under one month old and occasionally develops during 
the third and fourth years. It is also true that the hygienic sur- 
roundings have no influence on its occurrence. The previous 
condition of health is unimportant and diseases of the digestive 
tract do not predispose to its development. There is no evidence 
in any way satisfactory to suggest that it is microbic in origin. 
1 Amer. Jour. Diseases of Children, 1914, viii, 385. 



AND INFANT FEEDING 329 

Clinical experience apparently proves conclusively that scurvy 
is caused by some error in the diet. Furthermore, it seems to prove 
that it is due to some prolonged error in diet rather than to a 
temporary unsuitability of the food. The analysis of a considerable 
series of cases seems to show, moreover, that the disease is due to 
the lack of some essential element in the food rather than to the 
presence of some abnormal element or elements. Further than this 
the clinical evidence is rather unsatisfactory. It is true that 
scurvy is infinitely more common in artificially-fed infants than in 
the breast-fed. It does occur, however, in the breast-fed. This 
proves that it is not due simply to the lack of breast-milk. It 
occurs very frequently in babies that are taking proprietary foods 
prepared without milk. It occurs also in babies that are taking the 
proprietary foods prepared with milk and in babies that are taking 
milk without the addition of proprietary foods. These facts show 
that scurvy cannot be due simply to the presence of the proprietary 
foods or to either the presence or absence of milk in the diet. 
Scurvy occurs in babies that are taking condensed milk, boiled 
milk, pasteurized milk and raw milk, which apparently shows that 
the heating of milk, even if it is a factor in the production of scurvy, 
is not the only cause. The report of the Committee of the Amer- 
ican Pediatric Society in 1898 emphasizes the difficulties in arriving 
at the dietetic cause or causes of scurvy. They were only able to 
arrive at the conclusion, after a careful analysis of 379 cases, that 
"the farther a food is removed in character from the natural food 
of a child the more likely its use is to be followed by the develop- 
ment of scurvy." 1 The analysis of the authors' own cases shows 
the same discrepancy in the foods which were being taken when 
scurvy developed that has been found in all other series. It seems 
to show also, however, that the absence of "freshness" and the 
heating of the food are very important elements in the production 
of scurvy. In the more recent cases, overheating of the food was 
found in a larger proportion of the cases than was any other of 
the conditions to which it has been thought scurvy may be due. 2 

Effect of Heat. — It is very difficult to draw any positive conclu- 
sions from the literature of the subject as to whether the heating 
of milk, whether to the temperature of pasteurization or to that of 
boiling, produces scurvy in infants. The evidence presented is 
conflicting and inconclusive. In most instances the number of 
infants studied is small and the data as to the degree and duration 

1 Archives of Pediatrics, 1898, xv, 481. 

2 Morse: Jour. Amer. Med. Assn., 1906, xlvi, 1073, and Boston Medical and 
Surgical Journal, 1914, clxx, 504. 



330 DISEASES OF NUTRITION 

of the heating are incomplete. The statistics of Variot 1 and Carel 2 
which are always brought forward to show that the heating of milk 
does not cause scurvy, are of little or no value, because at the time 
when these observations were made scurvy was not sufficiently well 
known in France to be recognized unless of a most extreme type. 
The strongest evidence against the heating of milk being the 
cause of scurvy is found in the work of Lane-Clapon in the Infant 
Consultation of the Naunyn Strasse in Berlin, in which a consider- 
able series of babies were fed on boiled milk for long periods and 
did not develop scurvy. 3 

The strongest clinical evidence in favor of the view that the 
heating of milk produces scurvy is the fact that all large series of 
cases of scurvy show that a considerable proportion of the patients 
were fed on heated milk, more of them, however, on sterilized, 
boiled or scalded, than on pasteurized milk. 4 It is impossible to 
prove, however, that it was the heating of the milk and not the 
composition of the food which caused the scurvy in these babies. 
It is evident that when an individual baby is fed on a heated mod- 
ified milk it is impossible to know, if scurvy develops, whether it is 
due in the special case to the heating or to the composition of the 
milk. It can be only a matter of opinion. Further evidence against 
the heating of milk causing scurvy is that scurvy sometimes devel- 
ops in the breast-fed and in babies fed on raw milk. Still further 
evidence are Plantanza's observations 6 that although scurvy 
developed more frequently in babies fed on heated milk which 
was not used at once than on raw milk, it did not develop when 
fresh milk was heated and used at once. 

The results of experiments on animals with raw and heated milk 
are few and inconclusive. So many other factors have entered into 
the experiments that the results are practically without value. 
The only investigation of importance is that of Frolich. 6 He was 
able to produce scorbutus in guinea pigs by exclusive feeding with 
either raw or cooked cow's milk, although not as perfectly as by 
exclusive grain feeding. When fed on oats and raw milk they did 

1 Variot: Compt. rend. Acad. d. Sci., 1904, cxxxix, p. 1002. 

2 Carel: Le lait sterilise These de Paris, 1902-3. 

3 Reports to the Local Government Board on Public Health, 1912, New 
Series, No. 63. The literature of the subject up to this time is given in this 
article. 

4 Sill: Medical Record, New York, 1902, lxii, p. 1016; Hess and Fish: Amer. 
Jour. Dis. of Children, 1914, viii, 385; Morse, he. cit: Report Amer. Ped. 
Soc'y Archives of Pediatrics, 1898, xv, 481. 

6 Archiv. f. Kinderheilkunde., 1912, lviii, 155. 

6 Zeit. f. Hygiene u. Infectionskrankheiten, 1912, lxxii, 155. 



AND INFANT FEEDING 331 

not develop scorbutus, but when fed on oats and cooked milk they 
did. Bolle, and after him Bartenstein x tried the effect of heating 
milk and found that heating it for a short time had no especial 
effect on guinea pigs. When however, the milk was heated for a 
long time at a high temperature the guinea pigs died and single 
bones showed changes which Bolle identified as scorbutus. 

Experimental Scorbutus in Animals. — Hoist and Frolich were 
the first to produce scorbutus in animals, in 1907. They and 
Fiirst have continued their work up to the present time. 2 Talbot 
and Peterson 3 have recently repeated and confirmed their experi- 
ments. They found that when guinea pigs were fed exclusively on 
various forms of bread and grain, they died in from four to six weeks 
of a disease which in its symptoms and pathological anatomy corre- 
sponded with human scorbutus. They believed that the symptoms 
and pathological changes were caused by the diet. Others claimed, 
however, that they were the result of inanition from starvation. 
They then fed guinea pigs on fresh white cabbage, dandelions or 
carrots in such small amounts that the animals lost from 30% to 
40% of their weight. None of these animals developed scorbutus, 
whereas animals that were fed on dried grains or bread and lost a 
like amount of weight or relatively a few grammes, showed scor- 
butic changes. These experiments proved conclusively that the 
scorbutic changes were not due to simple inanition. It is interest- 
ing to note in this connection that there are records of cases of 
human scorbutus which followed a diet which was the same or 
similar to that given to the guinea pigs. 

They found that scorbutus in guinea pigs is relieved or cured by 
fresh vegetables in the same way that it is in man. The anti- 
scorbutic properties of the vegetables are usually, if not always, 
weakened by the process of cooking, but are rarely entirely de- 
stroyed. There seems to be some connection between the in- 
tensity of the heat used in cooking and the loss of the therapeutic 
properties. For example, white cabbages are of less therapeutic 
value when they are cooked at from 110° C. to 120° C. than when 
they are boiled. 

The fresh vegetables lose their antiscorbutic properties in vary- 
ing degrees when they are dried. Among those which they in- 

1 Bolle and Bartenstein: quoted by Hart, Virchow's Archiv. f. path. Anat. 
u. Phys., 1912, ccviii, 367. 

2 Hoist and Frolich: Journal of Hygiene, Cambridge, 1907, vii, 619; Norsk 
Magazin for Laegevedenskaben, 1910, lxxi, No. 3; Zeit. f. Hygiene u. Infec- 
tionskrankheiten, 1912, lxxii, Part One; Furst: Norsk Magazin for Laegeveden- 
skaben, 1912, lxxiii, No. 1. 

3 Boston Medical and Surgical Journal, 1913, cbrix, 232. 



332 DISEASES OF NUTRITION 

vestigated are potatoes, carrots, dandelions and white cabbage. 
These vegetables are affected differently by drying. Dandelions 
lose their therapeutic value immediately on drying, while white 
cabbage retains it longer when kept in an open vessel in an in- 
cubator at 37° C. than when it is kept at room temperature. 
Freshly pressed cabbage juice quickly loses its antiscorbutic proper- 
ties when it is heated at from 60° C. to 100° C. for ten minutes. 
The same thing happens when it is preserved for a long time either 
at room temperature or in an ice chest. Pressed dandelion 
juice also loses its prophylactic properties when heated for a 
short time. 

/ In contradistinction to the above, lemon juice will withstand for 
a long time the same heat that will weaken or entirely destroy the 
virtue of white cabbage or dandelion juice. Raspberry juice can 
be cooked for one hour at 100° C. without losing any of its anti- 
scorbutic properties. Hoist and Frolich thought there must be 
some connection between the acidity of these juices and their 
antiscorbutic properties and they were able to increase the resist- 
ance of white cabbage and dandelion juice to heat by the addition 
of acids. They were not able to increase this resistance so that it 
would stand prolonged heating. They were unable to determine 
the nature of the antiscorbutic bodies by dialysis, by extraction or 
other experimental methods. / 

Ftirst * found that the feeding of guinea pigs exclusively on plant 
seeds would produce scorbutus, although not so easily and regularly 
as exclusively grain feeding. Plant seeds that produced scurvy ac- 
quired antiscorbutic properties when infected with fungi. He 
concluded from his experiments that neither the ash nor any of its 
alkalis plays any part in the incidence of scorbutus. There was 
no apparent connection between the fat, alkali, carbohydrate, 
cellulose or enzymes in the food and the appearance of the 
disease. 

Hart 2 was able to produce scorbutus, characteristic in both its 
symptoms and pathological anatomy, by feeding monkeys ex- 
clusively on trade condensed milk. They were kept in such good 
surroundings that they did not become rachitic. Control animals 
fed on a mixed diet did not develop scurvy. His results were 
confirmed by Dodd. 3 

Heubner and Lippschultz 4 fed dogs for many weeks on a 

1 Zeit. f. Hyg. u. Infectionskrankheiten, 1912, lxxii, 121. 

2 Virchow's Archiv. f. path. Anat. u. Phys., 1912, ccviii, 367. 

3 Boston Medical and Surgical Journal, 1913, clxix, 237. 

4 Quoted by Hart: Virchow's Arch. f. path. Anat. u. Phys., 1912, ccviii, 367. 



AND INFANT FEEDING 333 

food poor in phosphorus and found microscopic changes in the 
bones very similar to those found in scorbutus. 

The results of these experiments hardly justify any very positive 
conclusions as to the cause of scurvy. They show very definitely, 
however, that scurvy is not due to starvation and that it is not 
brought on simply by the long-continued use of a single article of 
food. They suggest very strongly that when scurvy develops as 
the result of the continuous use of a single food, the trouble with 
the food is not that it contains some substance which causes scurvy 
but that it lacks some substance which prevents scurvy. They 
also seem to show that this substance which prevents scurvy is 
partially or wholly destroyed by drying and heating. They do not 
show whether this hypothetical substance is a single definite 
entity or a group of substances, closely related to each other and 
similar in their action. 

The Metabolism in Scorbutus. — Very little is known as to the 
metabolism in scurvy. The only accurate study on the metabolism 
of scorbutus in adults is that of Baumann and Howard l who found 
that the loss of the various food constituents through the feces was 
less when fruit juice was added to the diet. The total sulphur 
metabolism was abnormal throughout the experiment, the quantity 
eliminated being in excess of that ingested. Chlorine and sodium 
were retained during the fruit juice period, but were excreted in 
excess of the intake during the preliminary period. More potas- 
sium, calcium and magnesium were retained during the fruit 
juice period than during the preliminary period. Lusk and Kloc- 
man 2 studied the metabolism of nitrogen and the mineral salts in a 
typical case of scurvy in an infant eighteen months old. Observa- 
tions were made for three periods of four days each; the first 
while the disease was at its height and the child was not being 
treated; the second, after a month's treatment; and the third, a 
month later, after all symptoms had disappeared. The nitrogen 
balance was normal at all times. The balance of mineral salts, 
particularly of calcium, was somewhat increased in the first period; 
in the second period during convalescence it was markedly de- 
creased; and in the third period was approaching, but had not 
reached, the normal, although the child was clinically well. This 
is in decided contrast to the condition in rickets. These studies, 
while interesting, show nothing, however, as to the etiology of 
this disease. 

The Vitamins. — Funk has recently called attention to the 

1 Archives of Internal Medicine, 1912, ix, 665. 

2 Jahrb. f . Kinderheilkunde, 1912, lxxv, 663. 



334 DISEASES OF NUTRITION 

significance of the so-called vitamins in physiology and pathology, 
especially in relation to the etiology of what he calls the "avita- 
minoses," namely, beriberi, scorbutus, pellagra and rickets. 1 
He believes, and advances strong evidence to prove, that these 
diseases are due to the absence of certain vital substances in 
the food, that is, the vitamins. He shows from his own work and 
that of others that milk contains a considerable number of these 
antiscorbutic substances as well as a substance which materially 
favors the growth of young animals. The development of scurvy 
in infants taking foods which contain no milk may be explained, 
therefore, by assuming that these foods do not contain the essen- 
tial vitamins which milk does contain. The vitamins are, in 
general, very sensitive to heat. Those in milk are relatively stable. 
They are, however, partially destroyed by heating milk for a short 
time, and totally destroyed by long heating or sterilization. 
The development of scurvy in babies taking heated milk and the 
greater frequency of the disease when the food is boiled or sterilized 
than when it is pasteurized may be explained by assuming that the 
vitamins are partially or wholly destroyed by the heating, the 
destruction being more or less complete according to the degree 
and duration of the heating. Scurvy sometimes develops, however, 
in babies that are taking raw milk, or even in those that are on 
the breast. His explanation of the development of scurvy on a 
diet of raw milk is that in such instances the milk is deficient in 
vitamins. In support of this explanation he brings forward 
evidence to show that the amount of the vitamins in the milk 
varies with the amount of the vitamins in the food of the cows. 
An example of the influence of the food of the cows upon the 
amount of vitamins in the milk is the fact that their milk contains 
less vitamins in the winter, when they are eating dry food, than in 
the summer, when they are eating green food. The development 
of scurvy in infants on the breast may be explained in a similar 
way. He calls attention to the fact, moreover, that the vitamins 
are diminished in the milk of women who are underfed. 

Many objections can be raised to Funk's arguments and it may 
be urged that his premises are incorrect and his conclusions con- 
sequently not justified. Nevertheless, his proposition that scurvy 
is caused by the diminution or absence of certain essential vital 
elements, or vitamins, in the food, reconciles and explains the 
clinical facts and experimental evidence as to the etiology of this 
disease better than any other which has been advanced. 

1 Casimir Funk. Die Vitamine, etc., Wiesbaden: J. F. Bergman, 1914. 



AND INFANT FEEDING 335 

TREATMENT 

There is nothing in the pathological changes, in the causes 
underlying the hemorrhagic condition, or in the results obtained 
from studies of the metabolism in this disease which yields any 
information of value as to its treatment. The clinical and experi- 
mental evidence all goes to show, however, that the disease is 
due to the lack of some essential element or elements in the food, 
probably belonging to the class of vitamins. This same evidence 
also shows that these elements are likely to be deficient in foods 
which do not contain milk. It shows, too, that they are present in 
milk and that they are weakened or destroyed when milk is heated, 
the effect of the heating apparently depending on the degree of 
heat and the duration of the heating. They are almost invariably 
present in sufficient quantities in human milk. 

The indications furnished by this evidence as to the preventive 
treatment of scurvy are obvious. Babies should be nursed, when- 
ever this is in any way possible. If the supply of breast-milk is 
insufficient, they should be given all that there is in order to make 
up for any possible deficiency in the antiscorbutic elements in the 
artificial food. If it is necessary to use an artificial food, the basis 
of this food should be milk, which contains antiscorbutic elements. 
Unless the use of raw milk is for some reason contraindicated, the 
milk should be given raw, because heating milk almost certainly 
weakens its antiscorbutic properties. If it is necessary to heat the 
milk, it should be pasteurized at the lowest temperature con- 
sistent with safety, in order that these properties may be weakened 
as little as possible. If it is necessary to use heated milk con- 
tinuously, antiscorbutics should be given in addition. Babies 
should not be given foods for any considerable length of time 
which do not contain milk. 

/ It has been known for many years that fresh vegetables and 
fruits contain elements which cure scurvy. The antiscorbutic 
properties of fruits are in general greater than those of vegetables. 
These properties are present in the fruit juices. Fruit juices can 
be easily given to babies; vegetable and vegetable juices are less 
suitable for them. The most available fruit juices are those of 
the lemon and orange. Babies prefer the taste of orange juice to 
that of lemon juice and it is less likely to disturb the digestion. 
Orange juice should be used, therefore, in the treatment of scurvy, 
if it is easily procurable. It should be given in doses of one ounce 
daily. Less than this amount is liable to be ineffective, and 
experience has shown that more than this is unnecessary. It is 



336 DISEASES OF NUTRITION 

best given in one dose, one hour before a feeding, when the stomach 
contains but little milk. It is less likely to disturb the digestion if 
given in this way. There is no objection to diluting it with water 
or to adding cane sugar to it, if the babies object to it plain. The 
boiling of orange juice does not lessen its therapeutic value. It 
does not, however, increase it. There is, therefore, no object in 
boiling it. The juice of the orange peel also contains antiscorbutic 
elements. 1 The only reason for using it instead of orange juice 
is for the sake of economy. / 

Since orange juice and lemon juice are so easily procurable, and 
since they are probably the most powerful antiscorbutics, it hardly 
seems necessary to consider vegetables and other fruits, even 
though they also will cure scurvy. An exception may perhaps be 
made in the case of potato, which is easily procured and inexpen- 
sive. The potato should be boiled and mashed and given in doses 
of at least a tablespoonful daily. Hess and Fish 2 have suggested 
the use of potato water instead of the cereal waters in the prepara- 
tion of foods for infants as a preventive of scurvy. 

Scurvy can also be cured by a change in the character of the 
food. Human milk will cure scurvy. The substitution of a food 
containing milk for one which does not or stopping the heating of 
the milk will usually cure it. Recovery is slow under these cir- 
cumstances, however, while it is very rapid when orange juice is 
given. It is inadvisable, therefore, to trust to a change in the 
food to cure the disease. Orange juice will cure it, even if the food 
which caused the scurvy is continued. It is wiser, however, to 
change the food unless there is some special reason in connection 
with the baby's digestive capacity for continuing it. 

Cod-liver oil and olive oil do not either prevent or cure scurvy. 
There are no drugs which have any influence upon it. 

1 Hess and Fish: Amer. Jour. Dis. of Children, 1914, viii, 385. 

2 Loc. cit. 



INDEX 



Acidosis, 261 
Agar-agar, 312 

Albumin milk, 36, 205, 209, 266, 274, 
285 

caloric value of, 210 

composition of, 209 

preparation of, 209 
Albumin water, 285, 286 
Alimentary Decomposition. (See In- 
fantile Atrophy.) 
Alkalies: 

action of, in digestion, 11 

effect on curdling milk, 151, 203, 
274 

use of, in artificial feeding, 203 

in spasm of pylorus, 245 
Amino acids, 41 
Amylopsin, 13, 30 
Anaphylaxis, 45 

Artificial feeding. (See Feeding.) 
Ash. (See Mineral Salts.) 

B 

Babcock test for fat, 216 
Bacteria: 

dysentery bacillus, 76, 289, 294, 295 

effect of heat on, in cow's milk, 168 

gas bacillus, 76, 284, 289, 292, 295, 
297, 301 

in cow's milk, 162 

in cream, 191 

in human milk, 97 

in stools, 75 

lactic acid bacilli, 284 

pathogenic in stools, 76 

streptococci, 76, 289 
Bacteriology: 

of cow's milk, 162 

of gastrointestinal canal, 68 



Bacteriology — Continued 

of human milk, 96 

of indigestion with fermentation, 
280 

of infectious diarrhea, 289, 292 

of large intestine, 72 

of lower small intestine, 72 

of upper small intestine, 70 

of mouth, 68 

of stomach, 69 

of stools, 72, 86 
Barley water. (See Cereal Diluents.) 
Baths : 

cold pack, 302 

fan, 301 

sponge, 301 
Beef juice, 234, 285, 286 
Bicarbonate of soda, 204, 276 
Bile, 14, 15 

in human milk, 115 

in stools, 82, 83 
Bile ducts: 

congenital obliteration of, 27 
Bismuth salts, 284, 299 
Blood: 

in stools, 84 
Boiling of milk: 

as cause of constipation, 309 

changes produced by, 166 

effect on digestibility of, 169, 203, 
274 

in scurvy, 329 
Bran, 312 

Bread and Zwiebach, 235 
Breast-fed infant: 

normal, 131 

abnormal, 132 
Breast feeding. (See Feeding.) 
Breast glands, 93 
Breast milk. (See Milk, human.) 



337 



338 



INDEX 



Breast pumps, 129 
Breck feeder, 240 
Broth, 235, 285, 286 
Buttermilk: 

in artificial feeding, 205, 207, 297 

stools, 80 
Butyric acid, 69 



Calcium: 

in human milk, 109 

in cow's milk, 157, 318 

in scurvy, 328 

in treatment of rickets, 323 

metabolism of, 52, 318, 319 

metabolism in rickets, 318 

requirements, 319 

retention of water, 275 
Calomel, 275, 276, 283, 294, 313 

stools from, 276 
Calories (See Energy Metabolism), 
179 

caloric value of cow's milk, 164 

caloric value of human milk, 
111 

caloric needs of premature infants, 
238 

caloric requirements, 64, 185 

caloric values, 63, 192, 226 

clinical determination of caloric 
values, 226 

of albumin milk, 210 

of buttermilk, 207 

use of, in infant feeding, 185 
Cane sugar. (See Saccharose.) 
Carbohydrates: 

digestion and metabolism of, 29, 
32,34 

effect on protein digestion, 33, 48 

excretion in urine, 32 

ferments, 29 

forms of, 31 

indigestion, 87 

influence on calcium metabolism, 
321 

retention of mineral salts, 54 
Cascara sagrada, 313 



Casein: 

action of rennin on, 79, 149 

action of sodium citrate on coagu- 
lation, 152 

action of starch on coagulation, 
198 

chemistry of, 150 

coagulation of, 7 

curds, 41, 83 

determination in milk, 216 

effect of alkalies on coagulation, 
151 

in cow's milk, 154 

in human milk, 103 

indigestion from, 273 

relation of casein to whey-protein, 
201 

sulphur content, 104 
Castor oil, 275, 283, 288, 294, 313 
Catharsis, 276, 283, 301 

in constipation, 313 
Cereal diluents: 

action of, 198, 203, 274 

composition of, 198 

preparation of, 222 
Cereals, 234 
Chlorides: 

in cow's milk, 157 

in human milk, 110 

metabolism of, 54 
Cholera infantum, 303 
Chymosin. (See Rennin.) 
Citric acid: 

in cow's milk, 158 

in human milk, 110 
Cod liver oil, 324, 336 
Colic, 277 
Colostrum: 

corpuscles, 94 

cow's milk, 145 

human, 93 
Constipation: 

cane sugar in, 197 

fat in, 191, 309 

from starch, 199, 268, 309 

in indigestion, 259, 310 

in intestinal toxemia, 288 



INDEX 



339 



Constipation — Continued 

in new-born, 307 

in stenosis of pylorus, 248 
Cream : 

analysis of, 184, 217 

bacteria in, 191 

centrifugalized, 190 

gravity, 191, 217, 219 
Curds, 83 

casein, 41, 83, 198, 202, 203, 205, 
273, 274 

fat, 24, 83, 133, 260 

methods of prevention, 202 



D 



Dextrin, 31, 194, 195 
Dextrin-maltose mixtures: 

in artificial feeding, 193 

in indigestion, 266 

indigestion from, 267 

stools on, 80 

table of different forms, 194 
Dextrose, 31, 32, 195 

infusions, 297 
Diarrhea, 281 

carbohydrate in, 33, 193 

fat, 24 

infectious, 289 

nervous disturbances, 255 

nitrogen in, 49 
Digestants, 277 
Digestion: 

carbohydrate, 32 

effect of heat on digestibility of 
milk, 169 

fat, 18 

intestine, 16 

mineral salts in, 52 

mouth, 1 * 

physiology of, 1 

protein, 40 

starch, 30 

stomach, 3 
Diseases of gastrointestinal canal, 

243 
Disturbances of digestion, 257 



(See Albumin 



Eczema, 28 
Eggs, 235, 285 
"Eiweissmilch.' 

Milk.) 
Enemata, 313 
Energy metabolism, 56 

basal metabolism, 65 

and body surface, 59 

effect of fasting on, 58 

effect of muscular activity on, 58 

methods of computing, 57 

(See Calories.) 
Enterokinase, 14, 39 
Erepsin, 14, 16, 40 
Exudative diathesis, 28 



Fat: 

absorption of, 18, 22 

as cause of constipation, 309 

Babcock test for, 216 

curds, 83 

diarrhea, 24 

digestion and metabolism of, 18 

effect on protein metabolism, 48 

effect on salt metabolism, 54 

fat-splitting ferments, 18 

homogenization of, 190 

in cow's milk, 156 

in human milk, 105 

in infant feeding, 190 

in stools, 20, 22, 23, 24 

influence on calcium metabolism, 
320 

indigestion, 86 

modification of, in human milk, 136 

percentage of, in top milk, 218 

test for, in stools, 85 
Feeding, artificial: 

alkalies in, 203 

amount of food in twenty-four 
hours, 188, 189 

amount at single feeding, 188, 189 

animal milk basis of, 180 

boiling in, 203 

buttermilk in, 205 



340 



INDEX 



Feeding, artificial — Continued 

cow's milk most suitable, 181 

forms of sugar used in, 192 

general principles of, 179 

goat's milk in, 181 

high percentages of fat, 191 

indications for various sugars, 192 

intervals in, 186, 189 

mortality in, 89 

pancreatization in, 205 

protein in, 200 

regularity in, 187 

starch in, 197, 203 

table of foods for average infant, 
190 

variation of food elements, 190 

variation with age, 189 
Feeding, breast. (Also see Nursing.) 

ability to nurse, 90 

abnormal stools, 132, 133 

causes of failure to nurse, 122 

clinical considerations and tech- 
nique, 122 

contraindications to, 91 

difficulty in technique of, 128 

general considerations, 89 

indigestion in, 133 

intervals between nursings, 126 

modification of breast milk, 134 

mortality in, 89 

relative frequency of, 90 
Feeding during second year, 233 
Feeding intervals: 

on artificial food, 186 

on breast, 126 
Feeding, mixed, 123, 136 
Feeding, percentage. (See Percentage 

Feeding.) 
Ferments: 

action of heat on, in milk, 167 

carbohydrate splitting, 29, 197 

fat-splitting, 18 

human milk, 116 

in treatment, 278 

large intestine, 17 

mouth, 2, 29 

pancreas, 13, 29 



Ferments : — Continued 

proteolytic, 38 

small intestine, 16 

stomach, 8 

urine, 38 
Finkelstein's theories, 35 
Fissure of anus, 311 
Flatulence, 277 
Fruit juices, 332, 335 



Galactagogues, 112 
Galactose, 31 
Gastric. (See Stomach.) 
Globulin: 

in cow's milk, 103 

in human milk, 155 
Glycogen, 15, 32, 195, 196, 296 

H 

Hirschsprung's disease, 308 
Homogenized milk, 190 
Hydrochloric acid, 9 
Hyperpyrexia, 281, 286, 292, 301 
Hypodermoclysis, 300 



Ice bags, 302 
Inanition fever, 287 
Indigestion, 257, 279, 282, 293 

breast milk, 133 

carbohydrate, 196, 199, 263 

classification of, 258 

dextrin-maltose, 267 

etiology of, 257 

fat, 260 

from excitement, 256 

with fermentation, 279, 289, 293 

lactose, 265 

medicinal treatment of, 275 

from nervous exhaustion, 255 

from overfeeding, 258 

protein, 270 

saccharose, 267 

salts, 274 

starch, 199, 268 



INDEX 



341 



Indigestion — Continued 

stools in carbohydrate, 87, 265, 267, 
268 

stools in fat, 86 

stools in protein, 87, 271, 272, 273 
Infant mortality, 89 
Infantile atrophy, 25, 69, 262 
Infectious diarrhea, 279, 282, 289 

serum treatment of, 300 
Intestines, 16 

bacteriology, 70, 72 

large intestine, 17 

length of, 17 

secretions of, 16, 17, 30 

small intestine, 16 
Intestinal antiseptics, 284, 299 
Intussusception, 293 
Inunctions, 278 
Invertin, 16, 30 
Iodophilic bacteria, 270 
Iron: 

in cow's milk, 157 

in human milk, 109, 206 

metabolism of, 52 
Irrigation of colon, 276, 284, 288, 295, 
298, 301, 302, 305 

seepage, 300 

with silver nitrate solution, 299 

with sugar solution, 296 



Laboratories, milk. (See Milk Labo- 
ratories.) 
Lactalbumin: 

in cow's milk, 155 

in human milk, 103, 104 
Lactase, 16, 30, 31, 34 
Lactic acid, 1, 8, 69 
Lactose: 

effect on gastric motility, 7, 31 

in artificial feeding, 192 

in cow's milk, 156 

in human milk, 107 

indigestion from, 264 

modification of, in human milk, 136 
Lavage, 276, 305 

in spasm of pylorus, 246 



Lecithin: 

in cow's milk, 157 

in human milk, 108 
Levulose, 31 
Lime water, 153, 204 
Lipase, 11, 19 
Liver, 15 

cirrhosis of, 27 

fatty, 26 

weight of, 15 

M 

Magnesium: 

metabolism of, 53 
Maltase, 16, 30 
Maltose, 31, 194 

in artificial feeding, 192 
Marasmus. (See Infantile Atrophy.) 



of abdomen, 312 

in rickets, 326 
Meat, 236 

Meconium, 30, 39, 72, 78, 287 
Menstruation: 

effect on human milk, 115 

in relation to weaning, 137 
Metabolism: 

energy metabolism, 54 

fasting, 47 

in scurvy, 333 

of carbohydrates, 29, 34 

of calcium, 318 

of fat, 18, 21 

of mineral salts, 51 

of phosphorus, 322 

of protein, 46 
Milk certified, 176, 216 
Milk, comparative composition in dif- 
ferent animals, 159 
Milk, condensed, 229, 332 
Milk, cow's: 

action of rennin on, 149 

action of sodium citrate on, 152 

appearance, taste and smell, 146 

bactericidal action of, 168 

bacteriology of, 162 

caloric value of, 164 



342 



INDEX 



Milk, cow's — Continued 

casein, 154 

chemical composition of, 153 

chemistry and biology of, 145 

coagulation of, 147 

colostrum, 145 

comparison with human, 182 

determination of casein in, 216 

determination of fat in, 216 

determination of protein in, 216 

effect of alkalies on curdling, 
151 

effect of freezing on, 158 

fat in, 156 

globulin in, 155 

idiosyncrasy for, 181 

lactalbumin in, 155 

lactose in, 156 

lecithin in, 157 

microscopic appearance, 146 

mineral salts, 157 

nitrogenous bodies, 153 

of different breeds, 182 

precipitation with acids, 148 

reaction of, 146 

specific gravity, 146 

sterilization, boiling and pasteur- 
ization of, 166 

stools, 79 

tests for milk preservatives, 164 
Milk, "fat-free," 217 
Milk, frozen, 158 
Milk, goat's: 

analysis of, 160 

in artificial feeding, 181 
Milk, home modification of, 213 

calculation of starch mixtures, 222 

composition of materials used in, 
216, 220 

determination of caloric value of, 
226 

determination of percentages in, 
225 

determination of protein content, 
227 

methods of calculation, 218 

whey mixtures, 223 



Milk, human: 
abnormal, 130 
albumin in, 102 

appearance, taste and smell, 97 
bacteriology of, 96 
caloric value of, 111 
casein in, 103 

chemical composition of, 101 
chemistry and biology of, 93 
coagulation of, 99, 100 
colostrum, 93 
colostrum corpuscles, 94 
comparison with cow's, 182 
contraindications to, 266 
differentiation from other milks, 

116 
effect of nervousness on, 114, 136, 

271 
elimination of drugs in, 114 
estimation of amount of, 132 
fat, 105 

ferments of, 116 
for premature infants, 237 
globulin, 103 

indigestion from excess of, 258 
indigestion from excess of fat, 

260 
indigestion from excess of protein, 

270 
influence of food on composition of, 

111, 134 
lactalbumin, 103, 104 
lactose in, 107 
lecithin in, 108 
menstruation, effect on, 115 
microscopic appearance, 97 
mineral salts, 108 
modification of, 134, 271 
nitrogenous bodies in, 101 
opalisin, 103 

precipitation with acids, 100 
preservation by freezing, 144 
quantity of, 98 
reaction of, 98 
residual nitrogen, 102 
"running in" of, 122 
specific gravity of, 97 



INDEX 



343 



Milk, human — Continued 

toxic, antitoxic and immune sub- 
stances in, 119 

value of analysis of, 130, 131 

variations in composition of, 111 

uremia, effect on, 115 
Milk laboratories, 213 

prescription blank, 214 
Milk of magnesia, 276, 283, 294, 313 
Milk, modified, 182 

breeds of cows, 182 

determination of caloric values, 226 

determination of protein content, 
227 

mixed milk vs. milk of one cow, 183 

pancreatization, 227 

prescribing, 212 
Milk "peptonized," 228, 274 
Milk, skimmed, 217, 220 

stools, 79 
Milk sugar. (See Lactose.) 
Mineral salts: 

action in digestion, 52 

effect on protein metabolism, 48 

in cow's milk, 157 

in human milk, 108 

in indigestion, 206 

indigestion from, 274 

influence of other food elements on 
metabolism of, 51, 54 

influence on calcium metabolism, 
321 

lack of, in starchy foods, 199, 268 

metabolism of, 52 
Modification of milk: 

general principles, 183 
Motility: 

effect of food on, 6 

gastric, 7 
Mouth: 

bacteriology of, 68 

care of, 129 

digestion, 1 

ferments, 1, 2, 29 

reaction of, 1 
Mucus: 

in stools, 83 



N 

Nervous disturbances of digestive 
tract, 255 

diarrhea in, 255 
Nervous irritability, 282, 286, 294, 

301, 302 
New-born infant: 

composition of, 51, 307 

intestinal toxemia of, 286 
Nipples: 

care of, 128 
Nipple shields, 129 
Nitrogen. (See Protein.) 
Nursing: 

amount taken at single nursing, 127 

difficulty in technique of nursing, 
128 

duration of single nursing, 127 

intervals between nursings, 126 

method of, 129 

regularity of, 126 



Olive oil, 313, 336 
Opalisin: 

in human milk, 103 
Opium, 277, 300, 302, 306, 308 
Orange juice, 233, 312, 335 



Pancreas, 13 

secretions of, 13, 29 

weight of, 13, 14 
Pancreatization: 

in artificial feeding, 205, 227 
Paracasein, 150, 155 
Pasteurization of milk: 

changes produced by, 166 

effect on digestibility of, 169 

in scurvy, 329 

methods of, 273 
Pepsin, 8, 12, 38 
Percentage feeding, 184 

determination of percentages, 225 
Phenolphthalein, 313 
Phosphate of soda, 313 



344 



INDEX 



Phosphorus: 

metabolism of, 53 

in cow's milk, 157 

in human milk, 110 

in rickets, 322, 324 

in scurvy, 333 
Polycarbohydrates, 200 
Potassium: 

metabolism of, 54 
Potato, 235, 336 
Premature infant: 

amount of food for, 240 

artificial feeding of, 239 

caloric needs of, 238 

feeding intervals, 238 

human milk for, 237 

metabolism in, 237 

methods of feeding, 240 

secretions of, 2, 8, 10, 12, 13, 14, 16, 
28, 31, 237 

wet-nurses for, 141 
Proprietary foods: 

composition of, 230 

discussion of, 228 

in scurvy, 329 
Prostration, 281, 286, 292, 301, 302 
Protein: 

anaphylaxis, 45 

animal vs. vegetable, 201 

in artificial feeding, 200 

determination in milk, 216, 227 

digestion and metabolism of, 38 

ferments, 38 

fever, 44 

indigestion, 87, 270 

influence on calcium metabolism, 
320 

metabolism of, 47 

modification of, in human milk, 136 

need of infant, 179, 201 

nitrogen in cow's milk, 153 

nitrogen in human milk, 101 

retention and utilization of nitro- 
gen, 49 

salt metabolism, 54 
Protein milk. (See Albumin Milk.) 
Ptyalin, 2 



Pus: 

in stools, 84 
Pylorus: 

normal reflex, 8 

spasm of, 243, 250 

stenosis of, 244, 247 

R 
Reaction: 

of cow's milk, 146 

of human milk, 98 

of stomach, 7 

of stools, 22, 81 
Rennin, 8, 11, 38, 203 

action on cow's milk, 149 

action on human milk, 99, 100 
Respiratory quotient, 62 
Rickets, 262, 315, 327, 334 

artificial, 317 

cause of constipation, 310 

heated milk in, 171 

metabolism in, 318, 319 



S 



Saccharin, 278, 283, 288, 295 
Saccharose, 31 

in artificial feeding, 193, 196 

constipation from, 197 

indigestion from, 267 
Saliva, 2 

ferments of, 2, 3, 29 

secretion of, 2 
Salivary glands, 1 
Sclerema, 305 
Scurvy, 233, 327 

experimental, 331 

heated milk in, 171 

metabolism in, 333 
Secretin, 14, 39 

Soap stool, 22, 55, 87, 260, 261, 309 
Sodium: 

metabolism of, 54 

retention of water, 275 
Sodium citrate: 

action of, 11, 152, 205, 274 
Spasm of pylorus. (See Pylorus.) 



INDEX 



345 



Spasmophilic diathesis, 262 
Starch, 266, 296 

as cause of constipation, 309 

digestion of, 30, 31 

enema, 300 

foods, 232, 268 

indigestion, 268 

in infant feeding, 197 

malnutrition from, 269 

mixtures, 222 

as protective colloid, 198, 203 

in stools, 79, 84, 85, 268 
Starvation: 

acetonuria in, 47 

energy metabolism in, 58 

in treatment, 278, 283, 287, 288, 
295, 301 

metabolism in, 47 

stools in, 20, 46, 80 
Steapsin, 13 

Stenosis of pylorus. (See Pylorus.) 
Sterilization of milk: 

changes produced by, 166 

effect on digestibility of, 169 
Stimulation, 288, 300, 303, 306 
Stomach, 3 

absorption in, 12 

bactericidal powers of, 69 

bacteriology of, 69 

butyric acid in, 70 

capacity of, 4, 188 

carbohydrate-splitting ferments, 29 

digestion in, 5 

growth of, 3 

motility of, 7, 187 

position of, 3 

reaction of, 7 

secretion of, 8 

shape of, 3 
Stools, 77 

abnormal in breast fed, 132, 133 

animal foods, 80 

bacteriology of, 72, 86 

blood, 84 

buttermilk, 80 

carbohydrate indigestion, 87, 263, 
283 



Stools — Continued 

color of, 82 

cow's milk, 79 

curds, 24, 83 

dextrin-maltose, 80 

fat in, 20, 22, 23, 24 

fat indigestion, 86, 260, 261 

ferments in, 30, 34, 39 

in indigestion, casein, 273 
" " dextrin-maltose, 267 

" " lactose, 265 

whey, 272 
" " with fermentation, 

281 

in infectious diarrhea, 290 

in intestinal toxemia, 287 

in spasm of pylorus, 244 

membrane, 84 

microscopic examination of, 84 

mucus, 83 

number of bacteria in, 75 

odor of, 81 

of artificially fed, 79 

of breast fed, 78 

pathogenic bacteria in, 76 

protein indigestion, 87, 271, 286 

pus, 84 

reaction of, 22, 33, 81 

skimmed milk, 79 

starch, 79, 84, 268 

starvation, 20, 46, 80 

sugar in, 33 

whey, 79 
Sugars: 

energy value of, 63, 192 

excretion of, 35 

fever, 35, 193, 265 

forms of, 31 

in infant feeding, 192 

intoxication, 36 

in urine, 34, 196 

laxative action of, 34, 193, 195, 197 

limits of assimilation of, 37 
Sulphur: 

in casein, 104 

metabolism, 54 
Summer heat, 289 



346 



INDEX 



Suppositories, 313 
Syphilis: 

nursing in, 91, 97 



Tenesmus: 

treatment of, 300 
Thymus, 317 
Thyroid: 

in constipation, 307 

in rickets, 317 
"Top milk," 191, 217 

fat percentage in, 218 
Toxemia, intestinal, 282, 292, 293, 
301 

in infectious diarrhea, 289 

of new-born, 286 
Trypsin, 9, 13, 39 
Tryspinogen, 14 
Tubercular peritonitis, 27 

U 

Uremia: 

effect on human milk, 115 
Urine: 

in cholera infantum, 304 

in indigestion with fermentation, 
281 

in infectious diarrhea, 291, 294 

in scurvy, 328 

sugar in, 281, 292 



Vegetables: 

in constipation, 312 

in scurvy, 332 
Vitamins, 327, 333, 335 



Vomiting: 

excessive, 281, 286, 292, 294, 301 

habitual, 244, 252 

in indigestion, 276 

in nervous disturbances, 255 

in spasm of pylorus, 244 

in stenosis of pylorus, 248 

whey in, 202 

W 

Water: 

in diarrhea, 300 
Weaning, 137 

feeding after, 233 

indications for, 137 

menstruation in relation to, 137 

methods of, 138 

pregnancy in relation to, 137 

time of, 138 
Wet-nurses: 

general considerations, 141 

in indigestion, 260 

management of, 143 

methods of procuring, 144 

qualifications of, 142 

selection of, 143 
Whey, 266, 269, 274 

colloidal action of, 202 

composition of, 156 

indigestion from, 272 

in vomiting, 202, 245 

preparation of, 225 

stools, 79 
Whey mixtures, 202, 266, 269 

calculation of, 223 

for premature infants, 239 

stools, 79 



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